I hold a resentment for the invasion of Psychiatry by the Psychopharmacologists. I believe they belong, but when they came in the 1980’s, it was to the exclusion of everyone else. That’s not even true, it was more like "get on the bus or hit the road." Over the years, I’d largely accepted their need to dominate the field for a time as a reality. I assumed it was a paradigm having a heyday that would find its place in time. But I’ve been increasingly aware that some of it was an invasion financed by the pharmaceutical industry who were essentially trying to "buy" Psychiatry – and that parts of it have been an inside job. That’s infuriating to me.
My topic has to do with something specific. Drs. Nemeroff and Schatzberg have mounted a vigorous legal campaign against the charge in the recent POGO Letter to NIH on Ghostwriting Academics. They claim that the evidence that they lent their names to a ghost-written textbook is invalid because the evidence is circumstantial and doesn’t prove the charge beyond any reasonable doubt – a legal standard. I’ve figured out why that defense makes me so angry. That’s what this post is about.
The burden of severe depression:
a review of diagnostic challenges and treatment alternatives
J Psychiatr Res. 2007 Apr-Jun;41(3-4):189-206. Epub 2006 Jul 25.
by Nemeroff CB.
Department of Psychiatry and Behavioral Sciences
Emory University School of Medicine
ABSTRACT
Among the factors making recognition of severe depression problematic for clinicians are the heterogeneous nature of the condition, lack of standardized definitions, and concomitant comorbidities that confound differential diagnosis of symptoms. The spectrum of severity in depressive disorders is extraordinarily broad, and severity assessment is comprised of several metrics including symptom intensity, diagnostic subtypes, suicidality risk, and hospitalization status. The overall diagnosis is achieved through consideration of symptom types and severities together with the degree of functional impairment as assessed by the psychiatric interview. It is likely that no single fundamental neurobiological defect underlies severe depression. The chronicity and heterogeneity of this disorder lead to frequent clinic visits and a longer course of treatment; therefore, successful approaches may require an arsenal of treatments with numerous mechanisms of action. The categories of drugs used to treat severe depression are detailed herein, as are several non-pharmacologic options including a number of experimental treatments. Pharmacotherapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, atypical antidepressants such as serotonin-norepinephrine reuptake inhibitors and monoamine oxidase inhibitors, and combination and augmentation therapies. Drugs within each class are not equivalent, and efficacy may vary with symptom severity. Patient adherence makes tolerability another critical consideration in antidepressant choice. The role of non-pharmacological treatments such as electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation remain active avenues of investigation. Improved knowledge and treatment approaches for severe depression are necessary to facilitate remission, the ideal treatment goal.
Dr. Nemeroff is famous for talking about speculations, hypotheses, theories as if they are operating at a higher order of truth than even a lot of his colleagues. It’s a virtual reality where human depression already is a biological entity awaiting something like NASA, the Manhattan Project, or a Crick and Watson to crack the code. He leaves no room for grief, personality disorder, neurotic conflict, tangled past, tragic events, disordered life – things I saw frequently in my practice. And while I’ll be glad when someone finally isolates the group of depressed people that do have a proven neurobiological defect that responds to adjusting their specific chemical imbalance, that day has yet to arrive. But that’s not my point, not what has me so ticked about Drs. Nemeroff and Schatzberg becoming legalistic in response to that POGO article. It’s that the circumstantial evidence that they allowed their textbook to be written by a pharmaceutical company’s contracted ghost-writer is a hell of a lot more solid than the kind of evidence Dr. Nemeroff regularly gives in his semi-scientific review articles under the banner of "evidence based" medicine.
In the letter from his lawyer, Nemeroff claims that POGO Investigator Paul Thacker’s real motive in the charge is some kind of chronic criticism dating from Thacker’s days with Senator Grassley – a personal motive. Yet in that abstract above, Nemeroff has an undeclared personal interest in many of the treatments he mentions – and a direct financial stake in some. By the time this review was written, he’d already given up a prized editorship for not declaring his conflicts of interest, and here he’s doing it again. The same is true with the book in question. It was financed, purchased, and distributed by a pharmaceutical company Nemeroff is associated with and well paid by. The book presents that company’s drug in a stellar light compared to its actual track record. He was in contact with a ghost-writing firm known to be hired by that same company, and a proposal was made for them to write the book. That pharmaceutical company had a program to get articles published named "CASPPER" after the cartoon figure of a "friendly ghost." But POGO doesn’t have a surveillance video of the people at STI writing the book or a direct contract for ghost-writing, so Nemeroff and Shatzberg claim the allegations are unfounded.
So that’s my complaint. If Nemeroff is going to be remarkably loose with truth, proof, and motive in his own writing, he’s in no position to say "prove it beyond the shadow of a doubt." Medical ethics operates at the level of "give no appearance of" rather than fingerprints and DNA. He’s flunked "give no appearance of" in spades – repeatedly. He’s more in the realm of "quacks like a duck." What he’s inviting is for someone to rise to the challenge and do exactly that – prove the case[s] against him legally.
Your posts are very much appreciated.
Recalling a comment by Ralph some months ago that described Dr. Nemeroff showing up for his interview at Emory in a chauffeured Rolls Royce, I’d hazard a probability of around zero that Charles will be showing a measure of humility. Much more likely that he’ll sell the Rolls to pay his lawyers or that the dominant life forms on the planet will return to amoebae and protozoa before that. There’s also, it seems to me, to be an element of the cornered rat about him who isn’t caring a jot about right or wrong – only getting out of his uncomfortable circumstances by baring his teeth and making threatening noises.