1 Boring Old Man

As a child, I noticed that we had an odd book on our shelf – Mein Kampf by Adolf Hitler. When I got old enough to know what the book was about, I asked my Mom why she had it. She said she bought it  during the war to find out what Hitler said that got a whole country to go crazy, but she kept it for me. She said that when I was older, she hoped I’d read it to understand what had happened, so it would never happen again. Later in my youth, I did read it. What I understood even back then was Hitler’s trick [and my mother’s wisdom]. There was something wrong in Germany, Hitler could feel it. As that theme built, against his own resistance to the idea, he gradually had to accept the inescapable conclusion that the something wrong was the Jews. And then the book turned monsterous as he outlined what he had in mind to do about that. You know the rest of the story. Decades later, as a Psychiatry Resident, I read it again – this time as a treatise on Paranoia written from the inside. And over the years as a Psychiatrist, when I hear a patient stringing together cherry-picked events aiming towards some conspiracy theory [becoming paranoid], in my mind I’ve thought of them as having the Hitler feeling – "There’s something wrong and it’s dawning on me what it is."

I’ve only really had the Hitler feeling once myself – not that long ago. It was in September 2002 when the entire Bush Administration hit the airways one Sunday talking about Iraq and Saddam Hussein’s WMDs – the immediate danger right around the corner. I didn’t believe it. I thought it was a trick, and when I expressed my concerns, I got slammed as a non-patriot. Unfortunately, it was a trick. I was right that time – too right. It’s not a good thing, being right about a conspiracy theory. It makes you think you have some kind of keen intuition – fanning the flames of narcissism that hide inside us all.

So now I’ve got that Hitler feeling again. I think the Pharmaceutical Industry is trying to get rid of Psychiatrists and get the treatment of the mentally ill into the hands of Primary Care Physicians who will prescribe a lot more of their products. There I’ve said it out loud. I feel better already. Beside the fact that this has already happened, what little clues have I cherry-picked to make me think such a thing? Well, I thought it when I read that Drs. Nemeroff and Schatzberg had signed on to a industry-funded, ghost-written book, called Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care [a worthy cause…].

^{cover revised}

And I thought it when I read some articles by a Dr. Trivedi in Texas about simple computer algorithms to direct treatment of Depression [evidence-based medicine I…].

Then recently, I thought it when I read about Eli Lilly’s Viva Zyprexa campaign  because they said it outright in some of their suggested sales pitches [Zyprexa: the other early years…]:

STAR*D: What Have We Learned?
by A. John Rush, M.D.
Am J Psychiatry 164:201-204, February 2007

^{Dr. Rush has served as an advisor, consultant, or speaker for or received research support from Advanced Neuromodulation Systems, Inc.; Best Practice Project Management, Inc.; Bristol-Myers Squibb Company; Cyberonics, Inc.; Eli Lilly & Company; Forest Pharmaceuticals, Inc.; Gerson Lehman Group; GlaxoSmithKline; Healthcare Technology Systems, Inc.; Jazz Pharmaceuticals; Merck & Co., Inc.; the National Institute of Mental Health; Neuronetics; Ono Pharmaceutical; Organon USA Inc.; Personality Disorder Research Corp.; Pfizer Inc.; the Robert Wood Johnson Foundation; the Stanley Medical Research Institute; the Urban Institute; and Wyeth-Ayerst Laboratories Inc. He has equity holdings in Pfizer Inc and receives royalty/patent income from Guilford Publications and Healthcare Technology Systems, Inc.}
Dr. Freedman reviewed this editorial and found no evidence of influence from these relationships.

^{• "In addition, patients in primary care and psychiatric settings with major depression did not differ clinically except for slightly higher rates of general medical conditions in primary care settings, and slightly higher rates of prior suicide attempts in psychiatric settings."}
^{• "In terms of treatment tactics, STAR*D developed and implemented easily applied methods to enhance the quality of care in both daily practice and in clinical trials in representative groups of patients. This so-called ‘measurement-based care’ entailed the routine use of simple paper-and-pencil symptom and side effect measures at each treatment visit, along with guidance based on these measures to recommend timely dose or treatment changes. A likely consequence of this high-quality, consistent care was that outcomes in primary care and psychiatric settings were not different."}
^{• "Logically, primary care providers are well positioned — if given the time, staff support, and reimbursement support to deliver high-quality, measurement-based care — to conduct the first two treatment steps. Thereafter, more complex drug regimens are likely needed; the gains are likely to be lower; and the evidence base is truly sparse. Perhaps these steps are best left to specialists."}

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