1 Boring Old Man

^{Undoubtedly this is to the great delight of the anti-psychiatry community, lights up the antipsychiatry blogs [e.g., Carlat] who attract the Pharmascolds, scientologists and antimedication crowd who believe either there is no such thing as mental illness, that medication should not be used, or both. Did you know that psychiatric illnesses are pure inventions of Pharma and their experts to treat patients that do not exist with drugs that are dangerous and do not work with the purpose only of profiting themselves? Stop the profits! Make mental illness go away by legislation and committee! Treat human mental suffering with love and peace and all will be well! Who needs mental health professionals and their diabolical drugs anyway?}

^{Pharma have heard these protests loud and clear and are now pulling out of psychiatric research. Two of the biggest defectors are the two British companies Astra Zeneca and GSK, who have shuttered all their laboratories for mental health research for good, closing facilities all over the world including those the US, UK and Italy and elsewhere. Also, Pfizer bought Pharmacia/Upjohn and closed their CNS research center in Kalamazoo, Michigan; bought Parke Davis and closed their CNS research center in Ann Arbor, Michigan; bought Wyeth and closed their CNS research center in Princeton, NJ; and then for good measure closed their own CNS research center in the UK. Merck closed their CNS research center in the UK where I worked in the 1980s, then bought Organon/Schering Plough and closed their CNS research center in the UK/Scotland for good measure. I could go on and on…}

^{… the recognition that mental ill health is a complex mix of genetic and experiential factors. “This is not new,” he affirmed. “But what is new is the ability to probe the genetics of the disorder.” But whether the drug industry will take up the challenge, in the absence of plentiful molecular targets, is unclear, he suggested. “[It] has invested in me too compounds—and sometimes in compounds that are identical to someone else’s. And let’s be frank, that has worked really well for them,” he said. But he declared, “Antipsychotics and antidepressants are not very good.” Much more research into the biology of mental illness was needed, he said.}

If the crisis is not in the pharmaceutical industry, and it’s not with our patients, where is it? I can think of a several places. There’s a multi-billion dollar industry here and abroad that has come into being during the twenty-five years since Prozac was introduced to support the explosion in clinical trials: Clinical Research Organizations, Clinical Research Centers, Medical Writing Companies; Marketing firms, etc. They face the very real crisis of having nothing to do. Inside of psychiatry, there are a lot of practitioners who have lived out Insel’s Psychiatry-as-Clinical-Neuroscience metaphor, and only prescribe medications. I expect that the absence of new medications puts a real damper on their practices [since the Primary Care Physicians hand out the old medications like candy]. Likewise, the people who have made a career out of being on speaker’s bureaus or giving CME presentations [psychiatrists working for industry to promote new drugs] are also headed for an out-of-work crisis. More ominously, academic psychiatry has relied heavily on support from the pharmaceutical industry, and is likely to find its foundations sinking into the sand rather than resting on solid bedrock. One would predict that the city that has grown up around the boom economy of the recent past will look a lot more like a downtown Detroit in not too many years. That’s what happens when "bubbles" burst.

The 1950s ushered in a dramatic age of psychopharmacology with the introduction of Lithium, the Monoamine Oxidase Inhibitors, the Neuroleptic Antipsychotics, the Tricyclic Antidepressants, and the Benzodiazepines. The ensuing first fifty years of the American College of Neuropsychopharmacology has been an exciting time for drug research in psychiatry. The Selective Serotonin Reuptake Inhibitors came along in the late 1980s, the Atypical Antipsychotics in the 1990s; and those two classes of drugs are now near the top of the charts for pharmaceutical sales in the US today. So I expect that it does feel like generations of psychopharmaceuticals, one following the other, reaching back to the dawn of our remembered history. But Dr. Insel’s specific topic [Who will Develop the Next Generation of Medications for Mental Illness? The NIMH Perspective] seems slightly off-point to me. Dr. Nester’s Session topic is closer to the mark [Will We Have New Drugs or Not? Addressing the Crisis in Neuropsychiatric Drug Discovery]. Is the wave after wave of new pharmacologic treatments going to continue – currently simply awaiting the next breakthrough? Or is psychopharmacology entering a period of paradigm decline altogether?

As I understand the usual history of paradigms, when a new paradigm is introduced, there’s great excitement over its ability to clarify what was previously murky, or in the case of treatments, to treat formerly untreatable conditions. Next, the paradigm begins to be extended into areas beyond its original boundaries. But as time passes, the areas where the paradigm doesn’t add much begin to show. Even later, the downsides and limitations becomes increasingly apparent – eg adverse effects. In these later doldrums, when a new paradigm emerges – off we go again sailing on smooth waters. The old paradigm then slowly finds its proper, but appropriately circumscribed, place in the order of things.

There’s little question that psychopharmacology is in the doldrums right now with the dominant focus on the downside of the current medications – disappointing efficacy, adverse effects, and the disillusioning revelation that many in academic psychiatry and the pharmaceutical industry have colluded for some time in shameful and deceitful practices that discredit either as a resource for credible information. So even if there were new medications in the mythological pipeline, psychopharmacology would be in a period of paradigm decline based on the disinformation and disappointments accumulated for the last twenty-five years. I would hope some people at the ACNP conference in a few weeks understand that.