As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.
How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care. For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved.
Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.
Over all last year, drug makers spent $2.25 million on marketing payments, fees and travel expenses to Vermont doctors, hospitals and universities, a 2.3 percent increase over the prior year, the state said.
The number most likely represents a small fraction of drug makers’ total marketing expenditures to doctors since it does not include the costs of free drug samples or the salaries of sales representatives and their staff members. According to their income statements, drug makers generally spend twice as much to market drugs as they do to research them.
But this particular story is something I lived through. I don’t know if things were better in "the good old days," but I do know that they’re not better now. I guess it’s like Hippocrates learned a long time ago. What we call Medicine emerged from the many groups trying to improve the lot of afflicted people for two reasons. The first was obviously "science" – in Medicine, a treatment becomes accepted because it has been proved effective. Science isn’t about theories. Non-scientists have plenty of those too. Science is ultimately about results. A lot of people who have acute right lower abdominal pain, tenderness and fever don’t die if you take out their inflammed appendix. There are other causes for those symptoms, so there’s some more science involved – learning how to be relatively sure that any given patient is the one to be operated on. There’s a "cure" for appendicitis, but you’ll lose your operating room privileges if you take out too many normal appendices. Either you don’t know what you’re doing, or you’re lazy, or you’re greedy. No room in an operating suite for those kinds of people. So, besides "science," Hippocrates added something, an oath – "Do no harm."
What he was getting at is simple. He wasn’t just talking about charlatanism. He was talking about another monster – therapeutic zeal. When you’ve got a suffering person sitting in front of you, you want to do something. And in doing something, you can push the limits of solid science and hurt people. Give someone Penicillin for a viral infection [antibiotics don’t kill viruses], and they die from a penicillin allergy. Keep someone with arthritis on cortisone to make them feel better and their bones start breaking. The examples are as varied as ripples in a stream. And then there’s economics. Medicine is a profession. Money’s involved. You don’t make a living by having nothing to offer, by doing nothing. "That doctor didn’t do anything for me!" is a frequent complaint – but, in the words of Martha Stewart, often, "That’s a good thing." Sick people want three things: to be taken seriously; to be told that it’s not serious; and for their symptoms to go away. Medicine, itself, has other goals. Treat what can legitimately be treated. Relieve suffering if possible. Don’t contribute to suffering – by either therapeutic zeal, indifference, or personal financial motives. All of these things come under the umbrella of "Do no harm."
Medicine struggles with its advances. And Psychiatry is at the forefront of that struggle. The "illnesses" are elusive. There are no objective tests available to make diagnoses. It is, at best, a "soft science." Treatment results, likewise, are not always easy to measure. And there’s a greater interface with society as a whole – is a person "mad" or "bad?" It’s flaky at every turn. I loved it, myself. I came to Psychiatry and Psychoanalysis from a "hard science" background – medical research, Internal Medicine, mathematics. The reasons for the change aren’t relevant here, but the ambiguities of mental illness were fascinating to me – I never had a boring moment in my thirty years among the mentally ill. Every case was a challenge. Every unanswerable question was a great mystery. I think that one of the reasons for that was that my earlier career had cured me of a naive belief in "absolute truth." All truth is relative. The goal is to get as close to that truth as possible, always being aware that it will never be achieved. I’ve since learned that this attitude was called "Skepticism" [as opposed to "Dogmatism"] is ancient Greece and that it is the formal definition of "Liberalism." Today’s truth is tomorrow’s open question. What could be more exciting?
And I learned about scientific paradigms. Some new scientific idea bursts on the scene, and many old questions suddenly get answered. There’s a period of great excitement, and increasing new applications of the new idea are discovered on an almost daily basis. Then the exceptions begin to appear, and the negative consequences appear. People keep pushing forward with hope, but finally the new idea’s limits become clear and it finds it’s more limited place in the terapeutic armamentarium – appendectomies only for documented appendicitis. This is known as paradigm exhaustion. There’s a better term, actually – paradigm competition. The new idea doesn’t go away. It finds its place in the world of ideas – only to be used when it’s the right thing to use. In Psychiatry, Psychology, Psychoanalysis, paradigms come and go with great regularity, and are very hard to evaluate because the "science" is so "soft," the outcomes are so hard to measure, and the suffering so great. The examples could go on forever. Bromides relieved anxiety, but caused "bromism." The march of "tranqillizers" are fine in the short term, but cause addiction in the long haul. Electroconvulsive therapy is a miracle for certain forms of Depression, but was massively overused in the middle of the last century. Even the hated psychosurgey helped certain intractably tortured patients, but was a horror for many others. Psychoanalysis and psychotherapy was a great leap forward, but was so over-utilized that it’s no longer paid for by medical insurors. Now, it’s in the world of psychotropic medication that a useful paradigm is in the realm of uncknowledged exhaustion.
"Real" medications began to appear in the 1950’s and 1960’s. They have been revolutionary, to be sure. They include the Antipsychotics, Lithium, Stimulants, Antidepressants, the so-called "Mood Stabilizers," and a new broad family of Antianxiety medications. During my lifetime in Psychiatry, these have been remarkable advances – truly remarkable. And, by the way, they’ve virtually destroyed Psychiatry – not completely, but pretty close. Beginning in the 1980’s, Departments of Psychiatry were taken over by the Psychopharmacologists – and the Drug Company money flowed like the Amazon. Psychotherapy became the tool of other mental health specialties, and Psychiatry became "medicalized." That is fine, except that the potential for abuse was enormous. Insurance now pays for a few brief visits to a Psychiatrist – just enough to pick the right drugs for the symptoms. And departments of Psychiatry became drug research centers – financed by Drug Companies. The issues in this article are the tip of a Titanic stopping iceberg. What happened to Psychiatry is very similar to what’s happened in Washington. I think of it as "follow the money." And if you’re a person who needs psychotherapy, you’re probably out of luck. Treatment is determined by resources more that careful diagnosis and assessment of need. The careful, systematic exploration of the personal mystery of mental illness is still available, but it takes some work to find it – and it takes some sizable resources to afford it. For most, welcome to the world of "ask your doctor if drug du jour is right for you."
So, are things better or worse? The answer is "yes."
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