the future remains in the haze…

Posted on Thursday 30 January 2014

January 26, 2014

The following story was recounted to me by someone who was there:
    He was indignant. Outraged, even. He was a department chair. A prominent psychiatrist and author of textbooks. A Key Opinion Leader in the field. How dare the New York Times question him? The psychiatry residents sat in silence as he went on his rant. Every other medical specialty does the same thing! How come they didn’t go after the orthopedic surgeons or the cardiologists, who made much more money from industry relationships than psychiatrists? They went after psychiatry and psychiatrists because of the stigma surrounding mental health. And what is this whole conflict of interest business, anyway? The New York Times even had an article on Michelle Obama’s clothing retailer having a conflict of interest. It’s ridiculous! And the senator who started all this, Senator Grassley? What about all of his campaign contributions? Does he have conflicts of interest?
He had more choice words for the Times and for Senator Grassley, but you get the idea. His mindset seemed to be that because what he was doing would ultimately help patients, he was beyond reproach as long as he was not committing any crimes. Since funding was limited, what was wrong with working with industry? When all the other specialties make more than psychiatrists, why shouldn’t psychiatrists take part in entrepreneurial activities?
I was traveling this weekend. When I got home several people had forwarded links to this post by Psycritic. I stopped reading right there and reread it to be sure that I hadn’t misread the first part – that this rant had been delivered to a group of trainees. I hadn’t misread it. Psycritic goes on to relate this story he heard to the one I’ve been writing about:
Not surprisingly, he is no longer the department chair. However, five years later, this mindset about conflicts of interest still remains with some [many?] of psychiatry’s leaders. How else to explain the recent revelations about David Kupfer, chair of the DSM-5 task force? He failed to disclose that he was part of a company making a dimensional assessment for depression, both during the DSM-5 process and on an article that he co-authored with his business partner, statistician Dr. Robert Gibbons, who seems to be creating a commercial product with public money…
I wonder what our former chairman thought he was teaching those residents? how he understood why they sat in silence? what they thought about his self-serving reformulations [Every other medical specialty does the same thing!, They went after psychiatry and psychiatrists because of the stigma surrounding mental health, what is this whole conflict of interest business, anyway?]? Psycritic calls it a mindset which is probably a good way to characterize it. Later, he refers to it as Narcissisma powerful and dangerous thing, an even better way to categorize it.
The ends do not justify the means. Just because someone else is doing it doesn’t make it right. These may be rote lessons from childhood, but it seems that some people have conveniently forgotten them. In my opinion, this most likely happens not because of greed, but when people truly believe that they are doing good; therefore they must be good, and their critics must be bad. Narcissism is a powerful and dangerous thing. 
That’s well said. I’ll add a small refinement. One can define a Narcissist simply – they believe their own thoughts are right. We all do that part. But not this part – even in the face of overwhelming evidence to the contrary. Sound like paranoia? first cousins, siblings, something like that. If everybody isn’t clapping, they must be out to get you [clear in the example above]. How could someone capable of making such transparent excuses [like a kid on the elementary school playground that got caught throwing rocks or stealing someone’s lunch money] get to be a chairman of a department at a prestigious medical school? There were a number on Senator Grassley’s list [Chairmen and Narcissists], and many others who may not have made the list, but were contenders. In fact, some of psychiatry’s loudest critics have taken such people as the templates for all psychiatrists – self-serving Narcissists capable of rolling out this kind of bull-shit at the drop of a hat. Unfortunately, there’s an answer to the why-so-many? question. Here’s a taste of that answer from my corner of the world:
New York Times
October 3, 2008

… In 2004, Emory investigated Dr. Nemeroff’s outside consulting arrangements. In a 14-page report, Emory’s conflict of interest committee detailed multiple “serious” and “significant” violations of university procedures intended to protect patients. But the university apparently took little action against Dr. Nemeroff and made no effort to independently audit his consulting income, documents show. Universities, too, can benefit from the fame and money the deals can bring — a point Dr. Nemeroff made in a May 2000 letter stamped “confidential” that he sent to the dean of Emory’s medical school. The letter, which was part of a record from a Congressional hearing, addressed Dr. Nemeroff’s membership on a dozen corporate advisory boards…
    “Surely you remember that Smith-Kline Beecham Pharmaceuticals donated an endowed chair to the department and that there is some reasonable likelihood that Janssen Pharmaceuticals will do so as well,” he wrote. “In addition, Wyeth-Ayerst Pharmaceuticals has funded a Research Career Development Award program in the department, and I have asked both AstraZeneca Pharmaceuticals and Bristol-Meyers [sic] Squibb to do the same. Part of the rationale for their funding our faculty in such a manner would be my service on these boards”…
This is neither an excuse nor a reasonable explanation – just what happened. When I was at Emory twenty-five years before this article was written, we were flat broke. We had a department that had relied for decades on the NIMH, the State, the County, and some private hospitals for funds to pay our trainees and faculty. That was true in academia medicine-wide, but psychiatry didn’t have the means other specialties had to generate funding. We were operating on a wing and a prayer – running on fumes. So when people like Dr. Nemeroff came along who knew how to raise money, they were welcomed with open arms in lots of academic places in similar straits. By that time, I was gone from the full time faculty, but only a mile or two from my old office. And I watched with amazement as the department went from rags to riches. I knew it had to do with drugs and research, because that’s all they talked about, but like many, I missed the full extent of what that meant.

But back to the thread, that’s how we ended up with such a collection of people in high places – people who could raise money for the University Departments like the part in red above. And "the rationale for their funding our faculty in such a manner would be my service on these boards" wasn’t the full story. It was the alliance with the universities, their academic reputations, and their credentials that accounted for pharma’s generosity – a commerce that was mutually advantageous for quite a while. While I wouldn’t argue for a minute with either Psycritic’s assessment of the mindset in question or his diagnosis, the former chairman mentioned above and Emory’s Dr. Nemeroff below were pointing out that they were just doing what they were hired to do. And, by the way, they were lining their own pockets along the way. I’m not sure they were just thinking they were doing good as a rationalization, from their vantage, they were doing their jobs. While the back story of all of this is obvious now, it wasn’t so obvious before – wrapped in a cloak of science, research, discovery, evidence-based medicine, a lack of transparency, and whatever one calls the sweet smell of success.

I expect we know the answers to the questions now [what is this whole conflict of interest business, anyway? and why shouldn’t psychiatrists take part in entrepreneurial activities?]. It was ultimately a destructive and time-limited solution to a very real problem, one that hasn’t gone away – though for the most part, pharma has moved on down the road. When the past is still this close and the damage this apparent, the future remains in the haze. What we know for sure is "not this"…
    January 30, 2014 | 4:01 PM

    Great point, Mickey. Those chairmen were absolutely doing what they were hired to do. And I just want to emphasize here how much pressure academic institutions put on specialities like psychiatry, pediatrics, etc. that don’t tend to generate profits like procedural-based specialties. Another indication of how terrible the for-profit model is for healthcare.

    January 30, 2014 | 4:07 PM


    Well put again. Unfortunately, the specialties are left to deal with the wreckage left behind. And that pressure is still there to make it in the for-profit world we continue to live in.

    Steve Lucas
    January 30, 2014 | 4:28 PM

    I can identify on a different level. I belong to an old line denomination and can identify three ministers who are under professional psychiatric care, three more who have had questionable sexual contact with coworkers and at least two legal issues.

    When questioning the performance of those involved I have received the same response as noted above along with being told I do not have standing and that what is needed is for me not to question what is being done by those who have greater knowledge.

    The similarities are striking as is the response and continued failures.

    Steve Lucas

    January 30, 2014 | 9:24 PM

    Okay, so taking industry money and promoting its interests is bad form in the ancient art of medicine. When is someone going to explicitly connect the dots to patient harm? How long do the legions of injured patients have to stay invisible in this narrative?

    January 31, 2014 | 4:15 AM

    Thank you so much Alto for consistently raising these issues. As one who feels my life was destroyed by being on psych meds for several years and knows other people in similar situations, I would like an answer to this question also and feel very frustrated that the issue continues to be ignored.

    berit bj
    January 31, 2014 | 7:22 AM

    .Yes, the issue of patient harm continues to be ignored, by hoards of so-called experts, in this most lucrative field.
    In this little town in the south of Norway, we’re under more than 2 meters of snow, but infrastructure, shovels as well as small and huge machines are constantly going night and day keeping mainroads and my narrow, winding, steep street open. I’m impressed and thankful.
    But the public debate on the theme of psychiatry and harm done is just awful. Ignorant. Provincial. The debate in Denmark is more honest, Thanks to Peter Gøtzsche.

    Steve Lucas
    January 31, 2014 | 1:21 PM

    Patient, practicing physician, or church member we are all expected to go back and fight through the very people we are not only in conflict with, but who are also the decision makers.

    Steve Lucas

    January 31, 2014 | 7:05 PM

    Let’s ask our DSM grief experts about whether this woman was treated properly

    January 31, 2014 | 7:23 PM

    Thanks Alto. Speaking of grief experts, I forwarded that story to Joanne Cacciatore. Her recent article might be of interest.

    Nancy Wilson
    January 31, 2014 | 8:57 PM

    Here’s another one for the grief experts: slapping a diagnosis of MDD on women who have just been admitted to hospital for high obstetric risk (from Trivedi and friends).

    February 1, 2014 | 4:19 PM

    Every hormonal stage of a woman’s life is pathologized. The presumptuousness of psychiatry is breathtaking.

    It’s impossible for me to see this as any other than a vestige of misogyny in modern society. That psychiatry is its handmaiden — well, another black mark against the profession.

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