1 Boring Old Man

1. [used with a singular or plural verb] a system of moral principles: the ethics of a culture.
2. the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics.
3. moral principles, as of an individual: His ethics forbade betrayal of a confidence.

the distinctive character, spirit, and attitudes of a people, culture, era, etc: the revolutionary ethos.

It is the ethos or culture of medicine that defines us [primum non nocere – "first, do no harm"], and it is that very culture that has been under particular assault during the recent decades. And while psychiatry is not uniquely vulnerable among the medical specialties, it has been a place where the traditional ethos of medicine has faced some of its most difficult challenges. Last year, I reviewed some of the seemingly desperate treatments in the past [for review…] – things like Insulin Coma Therapy, Leucotomy, and Shock Therapies. They were all over-utilized, examples of one of the dangers to the medical ethic called therapeutic zeal. Since many of the illnesses treated by psychiatrists are desperate by themselves, when something comes along that works, it’s almost universally over-used – then the other side of the coin becomes apparent.

Another force in the ethos of medicine is a conflict that physicians of all ilks deal with every day. When any person develops a symptom, the felt experience in the face of an unexplained symptom is anxiety. So there’s a conflict between the physician and the afflicted patient. The patient’s goal is clear: they want someone to take their symptom seriously, they want it to have no consequences, and they want it to go away. The physician is by definition interested in knowing the cause, and is asking lots of questions and doing lots of poking, looking in places that aren’t often looked into, and maybe ordering lots of tests. So, number one is find the cause, later comes symptomatic treatment. It is the skilled doctor who negotiates that conflict easily. But in the ethos of medicine, that conflict is always alive and well. The patients want to feel better. Doctors want them to be patient. And in psychiatry as I know it, the term cause can mean anything from biology to psychology to relationships to poverty to anything else to ‘who knows?’ The patients still want to feel better, no matter the cause.

Medicine separated itself from the other healing arts based on primum non nocere – doctors didn’t drill holes in peoples heads anymore to treat headaches [except in ORs after an MRI showed something in there]. Our problem in psychiatry may have something to do with therapeutic zeal or patient’s wishes to feel better, but that’s not the center ring right now. It’s greed – just plain old, garden variety, human greed. It’s always been there. Why would anyone ever open a pharmaceutical manufacturing business except to make a profit? That’s not greed. That’s enterprise. Why wouldn’t a pharmaceutical manufacturer want to beat the competition? That’s not greed. That’s business. But when a drug company pays a medical writing company to ghost-write favorable scientific articles, and pays psychiatrists to sign on as authors, and they do it; or when that campaign results in harmfully medicating patients; or when side effects are hidden on purpose in the process; that’s greed – and the basic ethos of medicine has been violated and changed. Who is at fault? The whole culture that allowed such things to happen is at fault. And, as we are increasingly finding out, it happened a lot.

I think my own opinion about why this happened may be a minority view, because I personally think it happened beginning in 1980 with the coming of the DSM-III and as a corollary to the changes that were introduced with it. I didn’t then, nor do I now, believe that what we knew as Manic-Depressive Illness before was a mistake and that we were missing vast numbers of cases of Bipolar Illness as it’s now described and diagnosed. I didn’t believe then or now that there was a unitary category of Major Depression that consumed all the previous depressive diagnoses. I still see the claim that our diagnostic scheme is indicative of unique disorders [that multiply like rabbits with each revision] is built on fallacy. And I still believe that major psychiatric dis-ease can result from problems in the mind. In my opinion, the wish to "medicalize" psychiatry was little more than that – a wish. But that’s what we did – psychiatry became clinical neuroscience, almost overnight.

My problem is that unlike many of my psychoanalytic and psychotherapy-oriented colleagues, I think and always did think that neuroscience is pretty fascinating. I never met a data table or a graph I didn’t like. But when I look at the sea of Clinical Trials that now fill our journals, I don’t see much in the way of neuroscience. I see pseudoscience – maybe marketing research. The graphs, and tables, and statistics are there, but there’s so much obfuscation and manipulation that it’s hard for me to see the net culture as scientific. So we seem to have an ethos problem in our literature too – an all too regular betrayal of the scientific method. If you look at studies from over four or five years ago, there regularly aren’t honest statements about who wrote them, who actually did them, who had a conflict of interest, or many times, what the findings really were. This blog is filled with reviewed studies – many of which shouldn’t have been published, maybe shouldn’t have even been done. Now we’re getting to read some of the back-stories, about the ghost-writing, about the conflicts of interest, about the guest authors, about the spin, and one is left wondering at times if it’s just some kind of mass charade.

How would the change in 1980 lead us to this sorry state of affairs? Part of it came from the drug companies who jumped at the chance to throw money at a starving academic psychiatry. Part of it was the pressure from the pharmaceutical companies and 3rd party carriers for us to get medical. Part of it was a reaction against the era of the mind doctors [psychoanalysts, psychotherapsts] and the experientialists of the 60s and 70s. But we can’t get around the fact that a lot of people were literally "bought." There are just too many instances of Departmental Chairmen, APA officials, practicing psychiatrists, "kols," who made a lot of personal money by participating in some pretty shady dealings – things they couldn’t possibly have thought were on the up and up. I can’t see how anyone can be on a speaker’s bureau, using company slides, and trained in the company line, without knowing that they were not respecting the basic tenets of the ethos they were trained to practice in. To me, they were bought men and women, going over to the dark side. There’s really no other way to interpret the speaker’s bureaus or a lot of the industry funded CME presentations. And there’s absolutely no other way to explain the epidemic of jury-rigged studies in our journals.