In her testimony before the UK Public Accounts Committee in the earlier post [goldacre and godlee…
], Dr. Fiona Godlee says [@15:55]:
"Unless we can find a solution to the commercial incompetence problem, we have to recognize that the pharmaceutical industry has an irreducible conflict of interest in relation to the way it represents its drugs, in science and in marketing. And unless we can resolve this in a way that is more in the public interest and in patients’ interest, I would argue that drug companies should not be allowed to evaluate their own products."
While she made this comment as an aside towards the end of their argument for legislation mandating data transparency, she landed squarely on the story’s sticky wicket [in the spirit of the King’s English]. There’s been something of an unacknowledged Neurotic Contract with the pharmaceutical industry. "We’ll overlook some improprieties if you’ll be in charge of drug development." In psychiatry, that reached tragic-comic proportions in that a large segment of psychiatry has built itself around the pipeline of new drugs which it duly publicized and prescribed – an unfortunate symbiosis that seems to have had a lifespan of about twenty-five years. Now that the some improprieties and the duly publicized and prescribed is beginning to be seen in the sunlight, that landscape looks a lot different than it did along the way. Again, Dr. Godlee [@15:54]:
"I think secrecy doesn’t serve us well."
Simple and understated – the crux of the problem. Such Neurotic Contracts rely on secrecy, and when the lights come on, they always have this same what-were-they-thinking? look.
No American I know has ever seen a whole Cricket match. An understanding of the rules alone has been too contaminated by the simplicity of our baseball. Half a lifetime ago, I spent an afternoon trying to follow along in the company of a knowledgeable British neighbor. I couldn’t even figure out when to clap. The one thing I took from that day was his clarifying the meaning of a sticky wicket. It didn’t mean that the little top sticks [bails] wouldn’t fall off the upright sticks [stumps] when they were supposed to, a belief that apparently immediately identifies you as being from beyond the edges of the old Empire. It means playing on a damp field that makes the ball behave erratically. That’s likely wrong too, but it is with that definition that I proceed – playing on a difficult and unpredictable field.
Either data transparency or insisting on independent Clinical Trial validation seems inevitable to me – a reform whose time has come. In psychiatry, that carries something of a unique valence. Our specialty has increasingly migrated its practice to psychopharmacology with a small collection of medications, relying on the promise of new arrivals to make up for disappointments in efficacy and heavy side effect burdens. With the clarity of accurate information, those drugs have a diminishing appeal and the other end of the pipeline supplying new versions from industry is in a state of indefinite suspension. Many of us suspect that the recent revisions of the diagnostic manual were built on that same sandy beach as the over-reliance on inflated medication information and the fantasy of unlimited growth. And our organizations like the APA, the AACAP, and the NIMH seem to be still living nearby. Added to that, during the irrational exuberance of the last thirty years, the traditional tools of the trade were vilified and sent to pasture much to the delight of the third party carriers.
And so to our sticky wicket - we can’t predict our trajectory very well playing on this difficult field. In the coming crisis, where is the guidance, the compass pointing us in the right directions? Dr. Godlee offers us a simple one of immense value, "secrecy doesn’t serve us well." I think another comes from lessons learned in the last crisis if the 1970s. The solutions were built on revolution, devaluing the past, and moving ahead on the wings of fantasy. Besides throwing out the baby with the bathwater, it produced a vulnerability and a hunger that was easily exploited by the pharmaceutical and insurance industries abetted by the zealots within. And that identifies another compass point – being wary about making tempting alliances or following dangerous leaders in the process of finding new directions.
The obvious Anglophilia of this post was intenional – Ben Goldacre, Fiona Godlee, Cricket slang. The UK has our same problems, but operates in a more mature National Health Service and is playing on a less chaotic field. The forces for reform there are more organized [AllTrials, RIAT] and have a greater direct access to the seats of power. And finally, the clearest vision for the future I’ve read comes from the Critical Psychiatry Network
centered in the UK [see a long and lonely wait…
]. We would do well to listen carefully to the messages from the far side of the pond…