1 Boring Old Man

The Illusions of Psychiatry
The New York Review of Books
by Marcia Angell
July 14, 2011

In the late 1970s, the psychiatric profession struck back—hard. As Robert Whitaker tells it in Anatomy of an Epidemic, the medical director of the American Psychiatric Association [APA], Melvin Sabshin, declared in 1977 that “a vigorous effort to remedicalize psychiatry should be strongly supported,” and he launched an all-out media and public relations campaign to do exactly that. Psychiatry had a powerful weapon that its competitors lacked. Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible…

As psychiatry became a drug-intensive specialty, the pharmaceutical industry was quick to see the advantages of forming an alliance with the psychiatric profession. Drug companies began to lavish attention and largesse on psychiatrists, both individually and collectively, directly and indirectly. They showered gifts and free samples on practicing psychiatrists, hired them as consultants and speakers, bought them meals, helped pay for them to attend conferences, and supplied them with “educational” materials. When Minnesota and Vermont implemented “sunshine laws” that require drug companies to report all payments to doctors, psychiatrists were found to receive more money than physicians in any other specialty. The pharmaceutical industry also subsidizes meetings of the APA and other psychiatric conferences. About a fifth of APA funding now comes from drug companies.

Drug companies are particularly eager to win over faculty psychiatrists at prestigious academic medical centers. Called “key opinion leaders” [KOLs] by the industry, these are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs and, most importantly, largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them. Of the 170 contributors to the current version of the DSM [the DSM-IV-TR], almost all of whom would be described as KOLs, ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia…

We are coming to the end of a Bonanza in the world of the Neuropsychopharmacologists. The influx of support from the Pharmaceutical Industry in the last quarter century has meant that scientists interested in neuroscience and neurochemistry don’t have to compete so hard for paltry government research grants, institutional funding, or foundation money. The dangers are now painfully apparent to all of us, but that doesn’t change the fact that research is poorly supported otherwise. The Pharmaceutical companies are moving on – closing their CNS Research facilities and no longer pouring money into academic psychiatry. As their patents expire, the mythical pipeline [new drugs under development] is empty and they have nothing to sell. So the Neuropsychopharmacologists whose careers have spanned this period of plenty now see a desert stretching before them – their future on the wrong side of the supply and demand curve like that of the Pharmaceutical Industry that’s abandoning them for greener pastures.

I was frankly surprised by Dr. Krystal’s response to Dr. Angell’s review. He could have easily taken the high road and used her review to acknowledge the complaints about industry influence, share in the disappointments about the lack of progress, reaffirm the ACNP Principles of Professional Conduct, and perhaps take a hard look at his organization’s failings in dealing with the dark side and conflicts of interest. After all, Dr. Angell’s complaints weren’t aimed at the ACNP, but rather at the psychiatry, PHARMA, and the APA. Instead, he attacked Dr. Angell as an anti-psychiatrist and insensitive to the needs of psychiatric patients. Nobody reading those articles would agree with that characterization. He defended the achievements of neuroscience at the wrong time in history for that kind of defense. And he avoided the whole topic of conflicts of interest and the unholy alliance with the pharmaceutical industry. He spoke as if the ACNP ware the injured party, sounding like a Union Boss evoking the early principles of the Labor Movement while ignoring the graft and corruption that came in later days.

^{Angell has written an article filled with half-truths that would seem to call for society to abandon psychiatric diagnoses, antidepressant medications, and psychiatric neuroscience. Angell shows utter disregard for the negative impact of each of these actions on individuals with psychiatric disorders and society.  She provides no alternatives to the status quo or a constructive agenda that might ultimately speed the alleviation of human suffering.  Instead, she attacks the one clear path to better diagnoses and more effective pharmacotherapies, translational neuroscience.  By stigmatizing a field progressing toward a scientific foundation and by disparaging treatments that show signs of efficacy, Dr. Angell’s facile criticism of psychiatry could do harm.  Perhaps, in this case, doing harm in the name of ethics is, to borrow a phrase from Angell, a form of illusion.}

Last summer [actually around the time of Angell’s review], I realized that there was a dramatic change in rhetoric, and it came from multiple directions. I didn’t say it at the time, but it reminded me a lot of the post-911 period when all of a sudden the whole US government was talking about Saddam Hussein and Iraq. We know now that it was a carefully orchestrated campaign, but at the time, that wasn’t at all clear. But the change in rhetoric in psychiatry was equally striking [class action in the air…]. The DSM-5 Task Force backed down on their claim that they would put psychiatry on a firm biological footing [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5]. Dr. Jefferey Lieberman, heir apparent to the APA presidency, echoed the pull back but praised the promising future in a Medscape presentation [psychiatry inc…]. Dr. David Nutt delivered an impassioned speech at the Royal College Meeting in the UK defending psychopharmacology. Dr. Stephen Stahl raled at the "pharmascolds" and blamed them for the retreat of PHARMA from CNS drug development [myopia – uncorrected…]. Most striking, Dr. Tom Insel, Director of the NIMH, who had been the prophet of "Clinical Neuroscience" [Psychiatry as a Clinical Neuroscience Discipline] began to talk about the ineffectiveness of the current drugs, of course lobbying for an even more vigorous research effort [Brain circuitry model for mental illness will transform management, NIH mental health director says]. There was a meeting of KOLs at the Institute of Medicine to deliberate the crisis of PHARMA’s retreat [APF Convenes Unique Pipeline Summit]. By April, I was still struck with the collective change in tune [suddenly, last summer…].

There was, of course, a paradox. Over this last year, the misbehavior of both PHARMA and psychiatry became increasingly public and the suits against the Pharmaceutical Companies have multiplied with escalating fines and settlements. The efficacy of the current drugs was in question and the prevalence of adverse effects was on the front burner. On the other hand, the exit of PHARMA was met with a primal groan from all corners of the psychopharmacology world. The surface complaint was that there would be no new medicines for the sick, for the epidemic of mental illness [now that the wonder-drugs, the blockbusters that had fueled biological psychiatry for decades were now relegated to the "inadequate" category]. But it’s hard not to postulate an obvious under-belly – "There goes our funding", "There goes our reason for being".

So now back to Dr. Krystal’s one clear path to better diagnoses and more effective pharmacotherapies, translational neuroscience. Translational Medicine is the current buzz word of the N.I.H. I think it’s in response to the decrease in all new drug approvals by the F.D.A. The recently formed  National Center for Advancing Translational Sciences is for all of the N.I.H., not just the N.I.M.H., even though the acting director of N.C.A.T.S. is N.I.M.H. Director Tom Insel. Insel himself was in charge of a Translational Science program in Atlanta before he took over the N.I.M.H. in 2002. Come to think about it, Dr. Krystal’s bio on the Yale website says:

John H. Krystal MD

Robert L. McNeil Jr. Professor of Translational Research; Chair, Department of Psychiatry; Chief of Psychiatry, Yale-New Haven Hospital; Director: NIAAA Center for the Translational Neuroscience of Alcoholism; Director, Clinical Neuroscience Division, VA National Center for PTSD; Director, VA Alcohol Research Center; Medical Director, Schizophrenia Biological Research Center, DVA