1 Boring Old Man

^{hat tip to the librarians…}   

Boss of Bosses: Charles B. Nemeroff, MD, PhD

by James La Rossa Jr. and Genevieve Romano

TEN: The Economics of Neuroscience. 2000 2[9]:8.

Charlie Nemeroff is sitting quietly at the speaker’s table, ignoring the bustle going on around him. His face betrays nothing — neither boredom* nor interest, or apprehension. Only the blinking of his eyes distinguish him from a statue. When he hears his name he rises very slowly, and begins to move to the lectern with deliberate strides, gathering speed as he goes, brightening now. He breaks into a grin and begins speaking the minute he approaches the microphone and, before the hush of the room takes hold, he has won the crowd with a disarming and deliberate manner that cuts simply to the heart of the most complex issues in neuropsychiatry.

Charles B. Nemeroff, MD, PhD, chairman of the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine in Atlanta, finds himself addressing a room of crowded colleagues hundreds of times each year. Even in the ultra-competitive world of medicine and academia, Nemeroff is admittedly the most coveted academic speaker in psychiatry in the United States. His prolific authorship [he has published 600 research reports and reviews] along with a sheer enormity of research grants, awards, and scientific board appointments, has afforded him unprecedented celebrity within the psychiatric community. Nemeroff’s academic and intellectual largess translates to a small and influential group of close friends, including fellow department chairmen Alan Schatzberg [Stanford], Marty Keller [Brown], Dwight Evans [U-Penn], Bob Hirschfeld [U. of Texas, Galveston] and NIMH heavyweight Dennis Charney, all of whom spend a great deal of professional and personal time together. Psychiatry is a highly charged topic these days, and these six thought leaders walk a fine line between controversy and political correctness, often made possible by their strong allegiances both to topics and to one another.

The ethics surrounding the implementation of placebo-control trials is one of psychiatry’s most super-charged political issues, as is addressed in more detail in this issue of TEN. "From a scientific point of view, the best data on efficacy of any treatment is best derived from placebo-controlled trials," Nemeroff says. But with diseases like cancer and stroke, placebo trials become unethical. Thus, "the FDA in most cases has allowed for comparison between novel treatments for devastating disorders with traditional already-approved treatments." If a novel agent proves efficacious against en existing agent, it gets approved. But "that has not been the case in psychiatry. And we have to raise questions about the use of placebo in conditions like mania, where patients are terribly ill. [In these cases] one wonders why it isn’t sufficient to have evaluation based on ‘just-as-good-as’ or ‘better-than’ currently available treatments and better side effect profile."

Nemeroff is among the most coveted advisors to the pharmaceutical industry. Predictably, rumors about his alliances, or lack thereof, abound. It is safe to say that his views are expressed in a forceful manner — he is a passionate person — and he fully expects to lead the corporate strategy of those he advises. Those who do not heed his advice are often recipients of his wrath. Consequently, Nemeroff is often in favor with the most successful drug makers, since those firms are doing the lion’s share of research, which he often directs.

Privately, Nemeroff is circumspect about the role between private and public funding. Working with industry can "he a win-win. There is a shared vision but also separate mission – The university mission is a troika: research, teaching, clinical service; whereas the pharmaceutical industry [mission is to] discover new drugs and to market them effectively. Sometimes those goals are simpatico and sometimes they’re not." As an example of a situation where industry funding works to the benefit of the scientific community, Nemeroff recounts a new teaching council that he started recently with a grant from Janssen called The Young Faculty Development Program, where young professors get the opportunity to learn about clinical issues and academic life. And he talks also about the differences he sees between today’s young clinicians and those of his generation, "in the past, there was a clear schism between psychoanalytically oriented psychiatrists and so-called biological psychiatrists. Today, this mind-brain dualism seems silly … Patients of course have both minds and brains." The fact of the matter is that psychosocial factors … can certainly affect how the brain functions and we also know that the brain itself changes. The nature/nurture controversy is really no controversy, as we’ve improved our understanding of the brain."

The Bronx-NY-born Nemeroff is most content being both a researcher and a physician. As an example, he recounts a part of the very day of this phone interview. "[Earlier today] I saw four patients, one on emergency consult; at the same time, I was dealing with a number of issues related to an NIMH grant of the psychobiology of early trauma. What can be better than being a teacher and a researcher and a physician?"

By the turn of the century when this piece was written, Charlie Nemeroff was at at the top of the heap and the top of his game – the quintessential KOL. This article mentions some of the other major KOLs of the time, a core group of his friends and fellow chairmen. So as the new drugs flowed from industry at a steady rate, there was plenty to talk about, and the promise of future breakthroughs was always fertile ground for their stream of presentations and review articles. But that’s just the very public part. There were the advisory positions [left below] and those paid pharma speaker engagements to small groups all over the country [right below] generating personal income.

While this article was not written as an exposé, it offered a candid look behind the scenes at how Dr. Nemeroff and his colleagues occupied a formidable power-base in psychiatry in 2000, and hinted at how the boundary between academia and industry was disappearing. In the same year, responding to an article in the NEJM where Nemeroff and three other authors came from the group mentioned above [of the 29], editor Marcia Angell wrote an editorial, Is Academic Medicine for Sale? [after looking at the voluminous COI declarations]. Perhaps she could’ve even substituted bought and sold for for Sale, at least in the psychiatric literature on RCTs.

We all know how this story finally came to something of a close, though Nemeroff’s reign didn’t exactly end because of his industry connections – it was personal greed. In 2002, he published a review article recommending three different treatments all of which he had a personal financial stake in without disclosing that interest – easily seen by watchdogs Bernard Carroll and Bob Rubin. In spite of being publicly exposed and censured by Emory, in 2006 he did it again with a review of a treatment he and his coauthors all had financial interests in, again with no COI declarations [and in a journal he edited to boot], again seen by Drs. Carroll and Rubin. He was forced to step down as editor of the prestigious journal, Neuropsychopharmacology, and was put on a tight rein by Emory. But in 2008, when he was investigated by Senator Grassley for unreported pharma income, he lost his chairmanship [as did two of his cohorts on Senator Grassley’s list, Drs. Schatzberg and Keller].