1 Boring Old Man

I wrote this before the last post. Even as I wrote it, I knew I was writing it to myself, mainly to get things straight in my own thinking. But I changed my mind about posting it for two reasons. First, many of you aren’t psychiatrists and may not know the chronology so intimately – and I think it might help. History always seems to help me. Second, there’s something I want to say that has to do with George Dawson’s comment to the last post that won’t make sense without this. I apologize for the redundancies, where I lifted phrases to write the last post.

I was only casually aware of matters psychiatric during the 1960s. For me, it was the era of medical school, Internal Medicine training, and bench research. But from what I recall, the psychiatric residents got a generous government bonus for choosing the specialty. There was a shortage, it seems. In retrospect, that was because of de·Institionalization, and psychiatrists were needed to staff the Mental Health Centers that were to take their places as patients were moved from the hospitals into the community. By the latter half of the 1970s when I was in psychiatric training and early on the faculty, public mental health services were in crisis as the community services and hospital resources disappeared, even as the patient load from de·Institionalization grew [it was before they started filling up the jails and prisons]. Within psychiatry, there was a backlash against the prominence of psychoanalysts. Outside of psychiatry, the criticisms of psychiatry had a broad base: the heavy use of medications in treating psychosis; both the psychoanalytic and medical models; charging third party payers for psychotherapies; the question of whether mental illness was disease; the power of psychiatrists in involuntary commitment and medication. It was a tumultuous time. In the background, the revision of the diagnostic manual was marching towards release in 1980, a force that would make massive changes in the specialty and its practice. One part of that oft-told story is that those changes in psychiatry were orchestrated by the American Psychiatric Association [APA] under the guidance of its Board of Trustees, its Medical Director Dr. Melvin Sabshin, the chair of the DSM-III Task Force, Dr. Robert Spitzer, and the strong influence of the neoKraepelinians centered at Washington University in Saint Louis. Dr. Sabshin further consolidated the power of the APA by founding the American Psychiatric Publishing, Inc. [APPI].

The course of psychiatry in the US has been steered by the American Psychiatric Association since those 1980 changes. I don’t know if that central control was present before then, but it has certainly been true during my time. Many of us have withdrawn our membership for a variety of reasons in that time period. The medical·ization and medicine·ization of the specialty built through the ensuing quarter century, an era when much of academic and organized psychiatry was actively engaged with the pharmaceutical industry and the neuroscientific focus of the NIMH. It was a period of dramatic change with third party payers paying psychiatrists for outpatient medication management, and contracting with other specialties for psychosocial treatments. Another change – our prisons filled with chronic mental patients creeping toward the numbers of the confined prior to de·Institionalization.

The first decade of the new century began at the apogee of the now aging new psychiatry. The APA embarked on a DSM Revision that would realize a dream of connecting clinical diagnosis with measurable biology. Dr. Tom Insel of the NIMH advocated reframing psychiatry as Clinical Neuroscience. And the pharmaceutical industry was maintaining a steady pipeline of new medications coming onto the market [along with a publishing arm of its own]. But by the end of the decade, things were once again changing dramatically, as we all know. The involvement of academic psychiatrists with industry came to public attention with the revelations of Senator Grassley about unreported income, but the focus soon generalized to the whole issue of a corrupted alliances between a prominent sector of psychiatry and drug manufacturers – and we began to learn about ghost writing, and guest authorship, and industry financing out-front and in the background. Suits against pharmaceutical companies flourished exposing false advertising, exaggerated efficacy, minimizing of adverse reactions, and the involvement of the "KOLs" with industrial interests which became a source of public shame for us all. Meanwhile, the enthusiasm for a "biologic" DSM-5 choked in a desert of non-confirmation. Then the pipeline dried up, and PHARMA began to exit CNS drug development en masse. Quite an impressive decade of changes in fortune.

Here at the near midpoint of the second decade of the century, it would be hard to summarize the current state of play. We’ve seen several years of intense efforts to reform the clinical trials of drugs through Data Transparency, though at least in psychiatry, at present there’s not a lot of actual action in that arena with a dry pipeline – so, the "closing the stable door after the horse has bolted" adage seems to apply. The DSM-5 effort mercifully limped to its lackluster conclusion, but not before being abandoned by the NIMH, now creating a diagnostic system of its own – the Research Domain Criteria project [RDoC]. If anything, the DSM-5 Task Force process exposed the APA to further scorn – particularly with it’s chairman being exposed as involved in an entrepreneurial enterprise. And to complexify matters further, there’s another huge general issue on the table at the moment, the changing landscape of practice, finance, and health policy coming with the Affordable Care Act [ACA] among other things.