darwin 101…

Posted on Tuesday 16 June 2015

Five years ago, I was trying to explore the factors behind our medical schools tolerating all of the Academic Psychiatrists that were so allied with the pharmaceutical industries. I could find no way to quantitate how much money was flowing into the Universities from industry. But I could find out about NIMH money,  so I compiled the amounts coming to the University where I was on the faculty, Emory University. The PHARMA money was much more discretionary, but I thought the NIMH money might at least give us a sense of magnitude [see to bring in the money…]:
September 27, 2010
I’ve spent no small amount of time raling about the invasion of the Pharmaceutical Industry into Academic Medicine, specifically at Emory University where I trained and worked for some time. The Chairman, Dr. Charles Nemeroff, was relieved of his Chair in 2008 because of repeated Conflict of Interest violations. Since then, he has moved on to become the Chairman at the Miller School of Medicine in Miami. You might wonder why Miami would recruit a tarnished person, or why Emory put up with his antics so long. That question has an answer. Dr. Nemeroff came to Emory in 1991. At that time, the Department at Emory had no National Institute of Mental Health Grants. In the NIH/NIMH database, the funding amounts for grants only goes back 10 years, so I’ve shown the total number of grants above for the whole period and added the total funding below for the last decade:

Dr. Nemeroff came in 1991, and stepped down under a cloud of allegations in the Fall of 2008. By that year, the Department was bringing in 18 Million Dollars yearly from NIMH Grants [up from zero when he came]. And that only includes NIMH Government Grants. While I have no access to the amounts, there was also plenty of Pharmaceutical Industry money coming Emory’s way as well during those years through Dr. Nemeroff’s efforts.
I ran across that old post today and was amazed as I was the day I compiled it. That’s a lot of money, and there was plenty of PHARMA money coming in too – study grants and unrestricted institutional grants. I had wondered why the University had tolerated Nemeroff’s antics, but wonder no more. He came in 1991, and brought in an army of researchers who brought in the money. While this is a dramatic version, this trend was manifest all over the country. On a lark, I thought I’d look into what has happened since he was asked to step down in the wake of Senator Grassley’s expose of his personal PHARMA Income in 2008.

The research program Dr. Nemeroff built is holding its own. Obviously, the thing we would all like to know about is the PHARMA income coming in. What was it then? What is it now? There is no way I know of to get at those figures, but I’m absolutely sure that now is remarkably less than then [as PHARMA has moved on to greener pastures].

Unless you’ve been in Academic Medicine, you would have no way of knowing how medical education actually works. There is very little Institutional Support from the Universities. Much of the teaching is done by volunteer clinicians [unpaid]. In most medical specialties, the departments support themselves by delivering services – hospitals, clinics, etc. In psychiatry, we just don’t generate money like the rest of medicine – don’t even come close. In the 1950s and particularly 1960s, there was heavy government funding to support the Community Mental Health services flowering at the time. So departments of psychiatry were heavily invested in and supported by public medicine. In the 1970s, those resources were waning fast, and with Reagan’s election in 1980, they virtually disappeared. Managed Care was slashing psychiatric services at the same time [also a resource  for psychiatry departments]. Those were my days in academic medicine, and we were operating hand to mouth [on our best days].

So the government money from the NIMH heavily favored biological research; PHARMA was paying handsomely for academic connections offering lucrative institutional and product testing grants; and Managed Care was only paying psychiatrists to do medication management. Is it any wonder what happened in psychiatry? It was Darwin 101 – Natural Selection and Survival of the Fittest. Universities chose chairmen who could build like Charlie Nemeroff, who hired faculty who could bring in the government and PHARMA research money, and here we are today. That doesn’t make it right, but it’s what happened.
    Bernard Carroll
    June 16, 2015 | 9:14 AM

    Is it a Darwin 101 problem or is it rather a matter of perverse incentives? When I was a department chair I liked to remind the faculty that it was their department, not mine, and that quality mattered. More than once I dissuaded faculty members from pursuing easy money from NIMH, because it came with unwelcome strings attached and it would have distracted them from their more serious purposes. It would also have compromised their independence as clinical scientists. Among all those Emory grants you charted were out and out boondoggles that contributed nothing incisive to the advancement of clinical science.

    June 16, 2015 | 9:51 AM

    If you’d like to check out what Dr. Carroll is talking about, go to the NIH RePORTER and fill out these three fields on the Query Form there:

    Put emory in Organization. Put psychiatry in Department. Select either all or a specific year in Fiscal Year (FY): Then select SUBMIT QUERY. On the results page click FY in the header to sort by year [toggles ascending and descending]. Then checkout other universities. Watch out for the RePORTER. Once you figure out how to use it, it can become addicting…

    June 16, 2015 | 10:41 AM


    This is not a political comment on this particular post. I have been following your blog for a while now, I always study your posts and think of them and take them in, to the best of my understanding. I do not have any medical training.

    I have recently reinstated neuroleptic drugs for extreme protracted withdrawal syndrome. To put it simply. I did this at the advise of friends on survivingantidepressants.org.

    It seems to me you are someone who has extensive knowledge of neuroleptic drugs. My plan is to with draw extremely slowly. The problem I have is that one of the drugs I need to withdraw from in Seroquel. This is a very expensive drug and I am currently unable to work. I can go onto state but they do not supply Seroquel, but rather a generic. I am not sure which generic at this stage, they will let me know soon.

    My psychiatrist does not really believe in withdrawals, but he has been willing to listen. He suggested Truvalin as a substitute. I was wondering if perhaps you could help me see if that really is the same drug, etc, or if there are any other generics, or perhaps if you could point me in the direction of someone who could help me with this.

    I am extremely sensitive to any changes at this point, taking it one day at a time.

    I thank you deeply for reading my message and hope to hear from you soon. I also thank you for your blog and for trying to get the message out there about these neuroleptics and their effects, as well as the deeply rooted problems with our society and medical health paradigm.

    Wishing you warm regards,

    June 16, 2015 | 3:01 PM

    Whilel I find your Darwinian analogy interesting, I think this situation is more so the insidious nature that corruption and narcissism / anti social agenda does to decay the prior healthy boundaries that academic medicine should maintain.

    Once again, posts like this just reinforce to me that profit and care are completely incongruent. also, more and more academic leadership is so tainted and misguided at the very least, it’s only a matter of time before people should be held to felony charges.

    June 16, 2015 | 4:05 PM

    dear TJ,

    i’m not a doctor and i would recommend that you very very very very VERY VERY VERY VERY (i cannot say this enough times) carefully analyze ANYTHING someone tells you, whether it is on this site or not.

    one thing i will mention, aside from my reservations regarding the initial argument for putting you on medication (i’m not convinced this ‘syndrome’ you’ve been diagnosed with is legitimate), i recommend that you ‘taper off’ any drugs you feel uncomfortable with.

    tapering off means you continue your regular dosage, and then begin to incrementally-decrease it over the ensuing weeks. if you’re taking two capsules, for example, you’d start taking one for a week (maybe even two if you’ve taken them a while).

    you may need your doctor to prescribe different dosages to ensure that you’re not going from one large capsule to nothing, as this can have some adverse effects.

    for any neurological drug, i cannot stress enough how important the SLOW and PROGRESSIVE reduction of the dosage is key to reducign symptoms.

    whether you should be even taking seroquel for this alleged extreme protracted withdrawal syndrome is another topic i’ll leave to the accredited psychiatrists here (i’m not even in medical school, go figure).

    Steve Garlow
    June 16, 2015 | 4:24 PM

    I wonder if Dr Carroll has a typo in his comment. NIMH money has never been easy and does not come with strings attached and it is inconceivable to me that a department chairman would ever dissuade a faculty member from applying for NIMH funding. My understanding from talking to people who were in the department at Duke during Dr Carroll’s well regarded term as chair and director of the clinical research center was that there was a very strong emphasis on obtaining NIMH funding. PHARMA money is a different story and that money back in the SSRI era was relatively easy and did come with strings attached.

    James O'Brien, M.D.
    June 16, 2015 | 7:27 PM

    If neuroscience and biopharma uber alles has become 90% of psychiatric residency because of the influence of NIHM and pharma, you have to wonder if there are better alternatives with the objective of getting a comprehensive eduction in psychiatry. Like maybe doing a flex internship (so you can prescribe) then getting a Ph.D. in quant psychology or whatever you’re interested in. It’s not so far fetched. Consider where most analysts come from today vs. in 1960.

    I’ve commented elsewhere that I’d much rather hear a discussion between two older psychoanalysts over whether a short term improvement is due to transference cure vs. flight into health vs. a tedious Powerpoint lecture explaining why the latest me too drug is better than all the rest. Even when the analysts are wrong, they’re more interesting and more unpredictable.

    Bernard Carroll
    June 16, 2015 | 7:43 PM

    Hi, Dr. Garlow… no, there was no typo. Certain kinds of NIMH funding were easy to obtain if faculty members were willing to sign on to low-quality top-down mega-projects conceived and micro-managed by NIMH staff. But the money would have come with the consequences I mentioned above. Several faculty members were courted by NIMH staffers to join up and they struggled with this kind of decision until I told them to follow their own, independent scientific instincts.

    June 16, 2015 | 11:05 PM

    correct dr carroll,

    it’s high in number but extremely dismal on facilitating the scientific content and/or discovery.

    and they spend so much money on beaurocracy that you’re left with peanuts.

    June 16, 2015 | 11:11 PM

    to what dr garlow was saying:

    i agree that in *theory* the NIMH funding should be the most premium funding.currently however, the way it is being used is not. not only is this area difficult, but it requires an appreciation for solving the problem.

    isn’t that the way it should be though? problem is, someone is straight eatin’ funding that probably belongs to a more deserving psychiatrist. this is a big issue.

    this malaise is the reason (imo) the field of neurology and psychiatry both lack the direction.

    we live in a world of medical overspecialization to support the beaurocracy dr carroll spoke of.

    eventually this crony pyramid reveals who’s really taking the funding. that, i’ll let you guys figure out.

    seems like it’s the same people every time. and why not? ‘what are you going to do about it?’ 😉

    June 19, 2015 | 7:27 PM

    gagan sidhu, thank you for reinforcing the need for gradual tapering in response to TJ’s question.

    However, many patients find a decrease of 50% (one capsule a day rather than two) is far too precipitous. Sandy Steingard has found that, when it comes to neuroleptics, a decrease of 25% every few months is tolerable, but she still finds some individuals cannot tolerate that steep of a decrease.

    Because as peer support we cannot provide any kind of drug safety net, survivingantidepressants.org advises a very conservative taper of 10% per month, see http://survivingantidepressants.org/index.php?/topic/1024-why-taper-by-10-of-my-dosage/ to incur the least risk of withdrawal syndrome for the most people.

    Individuals may still suffer withdrawal syndrome when other, even similar, drugs are substituted; cross-tapering is preferable to cold switches for drug changes.

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