1 Boring Old Man

Two things happened at the same time. The first was that after five years of R&R in retirement, I agreed to work as a volunteer in a couple of charity clinics up here in North Georgia. Since I was going to be doing general clinic psychiatry instead of the psychotherapy that had been my practice in Atlanta, I decided to "brush up" on my psychopharmacology to learn about the new drugs and recommendations that had come along since I’d last looked. The second thing that happened was that the front page of my newspaper had psychiatry all over it when Senator Grassley began his investigations. Both things were beyond troubling.

The patients I saw were on bizarre medication regimens – lists of drugs without obvious logic. Some were on two, three, sometimes four antidepressants – frequently in doses that were out of the roof. Many were taking antipsychotics, in particular Seroquel, for sleep or anxiety – sometimes big doses. I saw children and adolescents on antidepressants that had labels that warned against their use in kids. But over and above the high doses and the polypharmacy, many of the people didn’t have the diseases the drugs were indicated for. They had something else – other diseases, bad lives, personality disorders, addiction, poverty. I was a stranger in a strange land, and the books I bought didn’t help me understand why people were being medicated like that [or much else].

And then there were the newspapers where I read about Department Chairmen [my Department Chairman] with unreported outside income, pharmaceutical speaker’s bureaus, "sponsored" CME advertising, ghost-writing, drug company advisory boards, blatant unacknowledged conflicts of interest that were the rule rather than the exception, clinical drug trials that made much ado about trivial significances – the list went on and on. And when I started reading about that and some of the psychiatric articles that were mentioned, I was anything but comforted. I had been a blogger since 2004 when Bush and Cheney were reelected. It wasn’t about conservative versus liberal for me. It was about lying, specifically in the lead-up to invading Iraq. And so I began writing instead about what I was learning about something much closer to home for me – my profession.

I had never been interested in entering the debate about the medicalization of psychiatry or "evidence-based" medicine. I knew what I thought – there was merit to both sides of what I really saw to be a false dichotomy. I found the demonization of psychotherapists like me painful, but I saw some of the point of the other side. I guess I saw it as the way things go in science, the ebb and flow of paradigms that sooner or later settles down and becomes less divisive. But when the magnitude of the invasion of psychiatry by non-medical forces began to become clear to me, I was enraged. Had I been repressing a fury left over from watching the things I had come into psychiatry to learn be attacked in caricature? Surely that was a part of it. But the central feeling was that I felt betrayed, and I think it was because psychiatry had actually been betrayed from within its own ranks. I’m right about that – independent of the part that has to do with my own biography.

As I’ve leaned more and more about what has happened in the last quarter century, I’m beginning to realize that while a lot of our current directions has come from external forces [the drug industry, the insurance industry, the hospital corporations], there’s a Cabal of psychiatrists who have willingly participated in shameful and sometimes outright unethical ways. They’ve turned a subsegment of their followers in the profession into detail men for the drug companies, and they’ve made a mockery of their own niche as biological psychiatrists by aiding their pharmaceutical colleagues in co-opting our literature for drug advertisements – not in the ad pages but in the articles themselves. The boundaries between business and medicine have become so blurred that some of them have even started drug companies of their own or opened labs and clinical research centers for profit. I’ve called them a fraternity of pseudoscientists, but I could have just as easily called many of them a gang of thieves.

I have other reasons for reflecting, but this one will do for starters. I practiced for twenty years a few miles from Emory after I left the full time faculty. I taught there in the analytic institute and in the college. I had a number of friends who worked full time in the department. But I had no idea of the dark side – ghostwriting, unreported outside pharmaceutical income, speaker’s bureaus, boss of bosses, unacknowledged conflicts of interest. I thought Dr. Nemeroff was a grandstander, but I had no idea about the other stuff. I expect that was true of any number of the academic KOLs whose misbehavior and alliance with PHARMA has been exposed recently. If I was that close and didn’t know what they were doing, they must’ve gone to some length to be stealthy. They hid all of this while preaching the self-righteous gospel of evidence-based medicine, and they clearly knew what they were doing. They deceived their students, their faculties, the psychiatrists who read their articles and books, and our patients. To my way of thinking, that deceit was criminal behavior and should be dealt with as such.