1 Boring Old Man

French philosopher, Alexandre Kojève, is known for an interpretation of the philosophical giant Georg Hegel – specifically the idea that we are at the end of history. I’m way out of my depth here, but it goes something like this: "The well-known ‘End of History‘ thesis advanced the idea that ideological history in a limited sense had ended with the French Revolution and the regime of Napoleon and that there was no longer a need for violent struggle to establish the ‘rational supremacy of the regime of rights and equal recognition.’" The shorthand version is that history [his story] is about mankind’s struggle over how we are to live and be governed in society, and we now know the answer. So the question is how to get there, not where we’re going – thus, the end of history. Kojève practiced what he preached by leaving the academic lectern to become one of the designers of the European Union. Well this post is on the way to the end of my little detour into history and one vantage on how psychiatry came to be where it is today, but the bottom line thesis is that psychiatry and everyone else focusing on mental illness, including its sufferers, are nowhere near the end of our history. At some fundamental level, we all sort of know that. We may be out of the gate, but we’re not nearly as far down the track as any of us would like to think – in either understanding cause or recommending treatment. There’s no place I can think of where the fable of the blind men and the elephant is a better fit:

We’re in one of those domains where expertise is a limited and limiting concept – where it’s often easier to see what’s wrong with what others think than to be clear about the limitations of our own understanding. That’s just how it is when you’re this far away from the end of a story [if it even has an end]. There’s little more interesting than unanswered questions; little more disquieting than unanswered questions; and little more dangerous than partial answers masquerading as the final word [I’ll bet there’s a Zen saying for that, but I just don’t know it. Maybe it’s all of them].

But mainstream psychiatry seems to have decided that we are at the end of history after all, that mental illness and/or its treatment is a biological matter. I’d reached no such conclusion and thought that the neoKraepelinian tenet, "the focus of psychiatric physicians should be on the biological aspects of illness," was an opinion. So I moved to the side. What woke me up and returned me to the fray was discovering that there had been a widespread cheating scandal afoot. Medicine doesn’t traditionally tolerate cheating scandals, but it seems to have allowed this one to go on for years. People were signing on as authors to papers they didn’t write, allowing professional data manipulators to spin the bad results of sponsors, hawking medications for personal and institutional financial rewards, pretending that massive conflicts of interest were immaterial, and filling our literature with commercialized pseudoscience that distorted the efficacy/safety equations of medications. And a lot of it came from the top, from the upper levels of academic psychiatry.

Why did that happen? It’s easy enough to condemn those among us who lack an ethical compass, but the extent of the problem suggests we need to look further, because there are lots of people who may not have participated explicitly, but have tolerated the widespread invasion of academic and organized psychiatry by the pharmaceutical industry without resistance – even defended it. And they seem terrified about the possibility of that alliance being brought under proper control or of an exodus of industry altogether. One part of that fear is clear, that the third party carriers or government programs will only pay psychiatrists for treatments that are medical – meaning writing prescriptions – or maybe that they’ll only pay psychiatrists well for that service. So psychopharmacologic treatment has made itself essential. But what I’m suggesting here is another less obvious factor, one I saw first hand back when all of this started. More than most other medical specialties, academic psychiatry has no easy way to support itself. The revenue stream from services in other specialties of medicine pays the training costs. But psychiatry has always gone from pillar to post in that regard, and been heavily dependent on public mental health funding or private hospital treatment for its training revenues.

With the collapse of both, we were heading for a real crisis at the time of the 1980 revolution. And the subsequent direct influx of pharmaceutical revenue into psychiatric departments apparently saved the day. The successful chairman became the one who could raise the biggest share of that revenue, hardly a healthy application of the principle of natural selection. It was an open door to corruption at the top and we’ve seen way too many examples. My University tolerated outrageous sheenanigans on the part of the psychiatry chairman and only acted definitively when he became a national disgrace the US Senate investigated. I can think of no other reason for that tolerance except that he delivered when it came to bringing home the bacon. We can’t have departments of psychiatry with their essential funding coming from the pharmaceutical industry and expect to make much progress in the area of reform of medication practices. And now, in the current climate when industry is pulling out of CNS drug development, psychiatric departments and education are headed for the same kind of financial crisis as the one we lived through thirty years ago.

The leaders in psychiatry seem to have a one track mind. The president-elect, Dr. Jeffrey Lieberman, is on Medscape with an appeal [Don’t Turn Your Back on Industry, but Keep It Honest]. The head of the NIMH, Dr. Tom Insel, is trying to find a way to make it easy for industry to stay involved [Experimental Medicine]. The APA/APF convened a summit to approach the same question [APF Convenes Unique Pipeline Summit]. The DSM-5 is about to be released slanted towards expanding target populations for medications. My reading of our history suggests that they’re stepping on the accelerator by appealing to a continued alliance with industry and perpetuating the conduit for corruption. It’s a time for putting on the brakes. If the real problem is funding for psychiatric departments for training, and parity in reimbursement for psychiatrists, that’s where our leadership needs to focus its attention.