1 Boring Old Man

Perpetuating Schizophrenia’s Stigma

New York Times: Opinion

By EDWARD LARKIN and IRENE HURFORD

AUG 12, 2014

Edward Larkin is a second-year medical student at the University of Pennsylvania, where Irene Hurford is an assistant professor in the department of psychiatry.  

A few months ago, a patient came to our hospital, seeking help. One of us, Edward, was on the team that treated him. He was pleasant, if slightly withdrawn, and cogent. He was a college graduate in his 20s and had recently been fired from his job as a high school math teacher, because of unexpected absences. He had come to believe that government agents were conspiring against him, and he had taken to living out of a truck and sleeping in different parking lots. By the time he came to us, he was exhausted. A diagnosis became clear: he had schizophrenia. We admitted him to the hospital, and after a few days, with his symptoms under control, we released him. Unfortunately, we prescribed a medication for him that could cause significant, permanent harm, instead of an equally effective drug with milder side effects — all because he was uninsured.

Schizophrenia, which affects 1 percent of the population and emerges in the late teens to early 20s, is deeply misunderstood. People who suffer from it are often suspected of being dangerous, but this is not usually the case, and antipsychotic drugs are very effective. Our patient was exactly the kind of person who, with the right treatment, could have weakened the stigma surrounding schizophrenia. Antipsychotic drugs fall into two classes: the older ones, like Haldol, and newer ones, like Abilify and Latuda. Both classes are equally effective at treating some of the worst symptoms of schizophrenia, specifically the hallucinations, delusions and paranoia that cause social alienation. [They’re not effective for treating “negative symptoms,” like low motivation].

But the older drugs can cause a multitude of serious side effects, including a potentially devastating one called tardive dyskinesia. This condition involves unsettling, animalistic smacking and wagging of the lips and tongue. At its extreme, it can affect the entire body. It occurs in 20 percent or more of patients who take the drugs long-term, and it tends to start so mildly that patients can’t identify it in time to stop taking the drugs. It is often irreversible.

The newer drugs have lower rates of tardive dyskinesia [estimates vary, but most likely less than half or one-third the risk], although they can cause weight gain and predisposition to diabetes, among other side effects. The newest among them, however, have decreased these risks, too. And a 2006 study showed that patients were more likely to keep taking the new drugs than the older ones.

Note from 1boringoldman: This 2006 study is from a proprietary Insurance Claims database with the following financing and ghost? authorship: "This study was supported by AstraZeneca Pharmaceuticals LP. The authors would like to acknowledge the assistance of Anusha Bolonna, PhD [PAREXEL MMS], who provided medical writing assistance on behalf of AstraZeneca."  [The article itself makes multiple pair-wise comparisons with no overall ANOVA to justify them, nor did it provide enough information to allow me to accurately estimate the overall ANOVA’s significance].

As a result, most psychiatrists prefer the newer drugs, especially for younger people, and they should have been the clear choice for our patient. He didn’t have the luxury of choice, however, because he was uninsured, and he was explicit about the fact that he didn’t have much money to spend on medications. So we had to prescribe him Haldol, which costs about $20 per month, instead of one of the newer drugs, which can cost more than $600 per month. These issues will be amplified as progress is made in discovering the mechanisms of psychiatric disease, as it likely will be, thanks to the billions of dollars that are now going to neuroscience research. We can already see the results of that kind of investment in oncology, where extravagantly expensive specialty drugs are coming on the market. But as we make much-needed progress and develop new, expensive treatments that are clearly superior to old, cheap ones, we have to ask: Will those with the most to gain still receive a lower standard of care?

 

So while his point holds that we aren’t taking good-enough care of Schizophrenic patients, it’s not our using the older medications that’s the problem [in fact, there are generic Atypicals now as available as the first generation antipsychotics]. Our failure is in offering little more than medications to his young patient and vague hopes for some future breakthrough medication that will fix everything.

Today, many argue that the growing crisis in health care stems from conflicts of interest and lack of access to clinical trial data. Our view is that small-print disclosure in academic footnotes and open access to trial data, important though these are, will not solve problems that stem from the notion that clinical trials provide a higher form of knowledge than knowledge borne in a clinical encounter – the realm of the experiential and the singular…

This ‘Trust in Numbers’ story was caught wonderfully when it was unfolding, by George Oppen, a New York poet and member of the communist party, in his 1968 volume Of Being Numerous:
Crusoe we say was rescued.
So we have chosen.
Obsessed, bewildered
By the shipwreck of the singular
We have chosen the meaning
Of being numerous.

beyond corruption…

Even in the best of circumstances – when protocols are followed precisely, diagnosis is rigorously pursued, analyses are pristine, conflict of interest is absent – a Randomized Clinical Trial is time-limited, and constrained by the measurement instruments selected, proxies like the HAM-D scale substituting for depressive affect. In addition, statistical significance or even effect size measurements don’t necessarily parallel clinical changes that make much of a difference. Subtle adverse effects often become apparent in a time-frame that exceeds the trial’s duration. In many cases, the cleanest of clinical trials can only say that the drug may possibly be effective and may possibly be safe.

beyond limitations…

In the case of psychiatry, the limits of the clinical trial are in bas relief. Unpleasant emotions themselves are not pathological – anything but. They are a part of an essential and elaborate warning system similar to physical pain. Among those presenting with emotional difficulties, primary disorders of the emotional system [Manic Depressive Illness, Melancholia, Anxiety disorders, psychosis, etc] are in the minority. In the majority whose emotional discomfort is related to some aspect of their life or personae, the use of emotion altering medications is highly dependent on the specifics. Likewise, the capacity to manage adverse effects, addiction, withdrawal, the downside of psychoactive medications, is as variable as ripples in the stream. A physical analogy might be the use of corticosteroids. For some, short-term use can be therapeutic. For others, it can be the introduction of a medication that can be over-used with disastrous consequences.

beyond groups…

After medical school and an internal medicine residency in a busy charity hospital where everyone was quite ill, I found myself in a military hospital on a base with healthy soldiers and their dependents – a very different place. My head was filled with facts and algorithms galore. But I had much to learn. The majority of patients had symptoms but rarely any of the dire illnesses that populated my mind. And I realized that a lot of my job was informed reassurance – a different role I had to learn to fill. Somewhere along those early days there, I realized that I was thinking in terms of case studies, talking less about diseases. A particular case comes to mind that goes with this topic:

She had been diagnosed with Idiopathic Thrombocytopenic Purpura, a condition where the platelets, cells involved in clotting, all but disappeared leading to easy bleeding. The wisdom of the time was that taking out the spleen would cure cases in kids under 13, but wasn’t helpful in kids over 13. She was 13 at diagnosis, and a splenectomy had been curative. When I saw her, she was thirty something, mother of two, and had consulted a gynecologist for heavy periods. She was referred because her blood smear showed no platelets and her platelet count was essentially zero. We did the workup and started her on the recommended anti-metabolite. We were rewarded with a rising platelet count. One day, she came in "itching," a sign of liver toxicity  and we watched with dismay as she became jaundiced and quite ill from our treatment. Her platelet count rose to normal, but it took a month for her liver function to return [to our great relief].
We sent her to the Air Force teaching hospital in Texas. When she returned, she was on another anti-metabolite [cousin to the one we used]. Our consulting hematologist sent us a stack of articles about treatment. Her platelets rose, but the itching returned, along with signs of liver failure. This time we stopped the medication more quickly and she didn’t get quite so sick. One day, I asked her about bleeding, and she said that except for heavy menses, it was no problem. I had been following protocol, and had given her two cases of liver failure chasing an abnormal lab test in an otherwise asymptomatic person, abetted by our best and brightest. We stopped the medications. Depot hormone shots eliminated her periods. And she did fine for the two years I followed her after that.

you can’t get it from books,
you can’t get it without books.

…small-print disclosure in academic footnotes and open access to trial data, important though these are, will not solve problems that stem from the notion that clinical trials provide a higher form of knowledge than knowledge borne in a clinical encounter…

beyond clinical trials…

The necessarily contained environment of a Randomized Clinical Trial is only a distant surrogate to that of the patients encountered in clinical practice, analogous to the relationship between the model airplane and the jumbo jet – a useful step, but hardly the full story. The cogent question is how did it come to be that the clinical trial has been escalated to some kind of gold standard for evidence based medicine rather than what it is – a minimum safety and efficacy requirement for FDA approval.

With the patient mentioned above, we saw her frequently. We made sure her husband’s next assignment was to a base stateside with a full hematology department [affiliated with a medical school]. He sold his Porsche and bought a Volvo after we cautioned them about car wrecks. But other than stopping her menstrual periods, it was what’s called benign neglect or watchful waiting.

… “The whole thing is profit driven,” says Michael Carome at Public Citizen, a consumer advocacy organization in Washington, D.C. “You can see where corners might be cut, looking the other way when there might be concerns about an investigator.” Some experts argue that the FDA’s entire rulebook for clinical trials, with its talk of things like “institutional” review boards, reflects the academic past of clinical research — not today’s industrial juggernaut of for-profit clinical trials firms and for-hire review boards, which oversee a workforce of doctors drawn from regular medical practice. “They are regulations for a world that doesn’t exist anymore,” says Elizabeth Woeckner, president of Citizens for Responsible Care and Research, which campaigns for the safety of medical research volunteers.

Many of our best and brightest scientists occupy themselves these days poring over the published scientific articles of others looking for evidence of illusion – the use of scientific and statistical methodology to either enhance weak signals or misrepresent negative findings. Others, like the Cochrane Collaboration, sift through the assembled literature hoping to find the studies with enough scientific rigor to be taken seriously. This has indeed become an age of meta·analysis – porting the application of critical science from the studies themselves to a later re·analyses of a group of studies, a laudable goal but one with an unfortunate built-in lag time – a science of science once removed. Likewise, the traditional scientific debate of letters to the editor or rapid responses [BMJ] require a vigilance not practiced by the majority of clinicians. So the counter to the scientific distortions in clinical trial reporting becomes a low hum overwhelmed by the music in the foreground.

The Best-Selling, Billion-Dollar Pills Tested on Homeless People

How the destitute and the mentally ill are being used as human lab rats

Matter

By Carl Elliott

June 29, 2014

Why Are Dope-addicted, Disgraced Doctors Running Our Drug Trials?

Matter

By Peter Aldhous

June 29, 2014

• Sovaldi Wins Round Two in the Battle to be the Best-Selling Drug
• Sovaldi, a Quantum Leap… Backwards to the Days Before Randomized Controlled Trials?

Glaxo is Probed by the FBI and the SEC Over China Bribery Scandal

Pharmalot: WSJ

By Ed Silverman

July 28, 2014

The scandal over bribery allegations in China has taken another discouraging turn for GlaxoSmithKline with the news that both the Federal Bureau of Investigation and Securities and Exchange Commission are conducting probes of the drug maker’s activities there, according to The Wall Street Journal. The disclosure comes amid ongoing turmoil for the drug maker after Chinese authorities recently accused the former head of Glaxo operations in China of ordering subordinates, his sales team and other employees to bribe hospitals, health care organizations and others on a large scale.

The drug maker tells the paper that it is cooperating with Chinese authorities and informed the U.S. Justice Department and the SEC of the Chinese investigation. A Glaxo spokesperson declined to comment to the paper about the FBI interviews, saying talks with regulators are confidential. The interest by U.S. authorities is not surprising, given that Glaxo disclosed in 2010 that U.S. authorities contacted the drug maker about its overseas operations as part of a wider probe into dealings by the pharmaceutical industry in other countries and the Foreign Corrupt Practices Act. The agencies more recently began looking at Glaxo practices in China following the allegations, the paper writes.

Meanwhile, bribery allegations concerning Glaxo operations have spread to other countries. Last week, Syria was added to a list that now includes Lebanon, Jordan, Iraq and Poland, according to a report that recounted information sent to Glaxo executives by a whistleblower. The scandal in China, of course, endangers Glaxo’s ability to build its business in a crucial market, but also undermines a pledge by Andrew Witty, the Glaxo chief executive, to transform the drug maker into a leading progenitor of improved business practices in the pharmaceutical industry…

Tut tut GSK

Pharmagossip

by Jack Friday

June 5, 2014

GlaxoSmithKline has confirmed it is going to pay a massive fine after admitting it mis-promoted a range of drugs in the US. The pharmaceutical company stated that it will pay $105 million [£63 million] settlement with 44 US states and the District of Columbia following the way the firm promoted anti-depressants Paxil and Wellbutrin and asthma medication Advair.

However, GSK did not admit any wrongdoing regarding the promotion of the medication and insisted that the money it is paying out is in relation to previous issues. "We don’t feel like this is who we are today," GSK spokeswoman Mary Anne Rhyne told the BBC. "These are historic matters – they relate back to the federal government settlement in 2012 so some of these events are as long ago as 14 years"…

My point is that when Mary Ann Rhyne says "These are historic matters," She means to imply that they are part of a distant past and no longer true. More accurately, these matters are the history of GSK since it came into existence in 2000 through merger, and persist to the present – obviously. Since the $3 B settlement in 2012, we’ve heard the "turning over a new leaf" routine over and over, but the truth is that it should have been "turning over new rocks" and finding some dark creature underneath each and every one of them. Is that a GSK problem, or a PHARMA problem? Is that a GSK history or a PHARMA history? Is corruption the history of PHARMA?

I would find it very hard to answer that question with a "No." Personally, I think I must’ve come into things during a lull period. I started medical school in 1963 right after the major reform of the Kefauver/Harris Act. I had a Lilly doctor bag, stethoscope, tuning fork, and reflex hammer. I learned a lot of anatomy from the CIBA atlases drawn by F. Netter. All pens and prescription pads had some pharmaceutical company’s name somewhere. I even knew a few detail men. But I don’t recall having any idea what company made what drug through medical school, through a medicine residency, through the Air Force, or during psychiatric training.That may be an artifact of training in big charity hospitals. My first awareness of what company made what drug came when Prozac came along in 1987 [and thereafter]. I never saw detail reps once in practice, and at medical meetings, I snunk through the exhibit areas collecting pens, pads, and rubber body parts [office supplies] while the pretty [and handsome] reps were otherwise engaged. I’ve learned that was an idiosyncratic way to be.

But I think, as I said, I came in a lull. It appears that the forces of regulation in the universe have been chasing the Pharmaceutical Industry from its origins in the days of Patent Medicines to the present, only to be periodically thrown off the scent by good behavior after one or another reform movement. But when things settle down, they’re up to their old tricks. We put up with their walks on the wild side because we count on them for new drug development. My own take on all of this is that it’s always a Faustian Bargain guaranteed to come to no good end, and we’d best rethink the whole thing. This may well be an area where capitalism can never work. It is really not a "free enterprise" in that patients, and to some extent doctors, are a captive audiences under the current system. And as for GSK, enough is long past enough…

Court Says Florida’s Ban on Physicians Discussing Gun Ownership Is Legal

PsychiatricNews

July 29, 2014

A federal appeals court has reversed a lower court’s ruling that Florida’s law limiting what physicians can discuss with their patients regarding gun ownership violates physicians’ First Amendment right to free speech. The lower court had issued an injunction in June 2012 against enforcing the law, which was signed by Florida Gov. Rick Scott [R] in June 2011.

APA, the AMA, and several other physician organizations had submitted an amicus curiae brief to the U.S. Court of Appeals for the 11th Circuit urging the justices to reject the state’s attempt to revive the law after the lower court decision, pointing out that asking about gun ownership and guns in the home is an important screening tool, like asking about substances of abuse, smoking, and eating habits, for example. But in its July 25 ruling, the appeals court found that the law did not violate free-speech rights but was instead a "legitimate regulation" of medical conduct in the service of providing patients with "good medical care." The majority of the appeals court panel ruled that the law "simply codifies that good medical care does not require inquiry or record keeping regarding firearms when unnecessary to a patient’s care…. Any burden the Act places on physician speech is thus entirely incidental." The justices also said that patients’ right to privacy regarding gun ownership takes precedence over physicians’ right to inquire about this subject.

Paul Appelbaum, M.D., past chair of the APA Committee on Judicial Action and the Dollard Professor of Psychiatry, Medicine, and Law at Columbia University, told Psychiatric News, "The 11th Circuit’s decision upholding Florida’s gag law is troubling because it is one more example of courts and legislatures attempting to control what doctors say to patients. Here, the judges have decided that asking routinely about the presence of guns is contrary to good medical practice and hence can be prohibited by the state. When courts set the standards for clinical interactions rather than leaving that task in medical hands, the inevitable result is harmful to the public’s health."

I was obviously devastated and announced that a full security clearance was a condition for my continuing to see patients in the military – and I was serious. It was quickly granted. The people in the military above me were as devastated as I was by this case. Our hospital was not equipped to stop that clot, even if we’d known about it, but we could’ve at least tried to get him somewhere that could’ve given it a shot in the couple of hours we had.

In the situation mentioned in this article, patients already have the right to privacy. So why is this question specifically singled out as an area that should be kept private from a physician? If you live in rural areas of this part of the country, you sort of know the answer. It’s a symbol of something like independence, or personal freedom – something like that – so the evil government can’t confiscate everybodies guns. Of course it’s craziness, but a craziness regularly capitalized on to get votes around here. For a State to pass such a law is part of that craziness and I hope the APA/AMA will join the appeal of this ridiculous law.

The only "author’s response" I’ve ever seen where the author of a medical paper admitted culpability in response to criticism was when Dr. Gibbons, Dr. Kupfer, et al apologized for lying about COI after being exposed. And in that apology, they didn’t get around to apologizing to Dr. Carroll for their initial nastygram in response to his criticism of their paper [careful watching…]. So I’m not surprised that Dr. Lu et al [Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study] defended their recent attempt to malign the Black Box Warning on antidepressants in youth. They’ve mounted two responses to the outcry about that flawed paper – both of which are filled with marshmallows and have the substance of the Pillsbury Dough·Boy.

Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study
Author’s Reply

by Christine Y. Lu, Gregory Simon, and Stephen Soumerai

British Medical Journal. 2014 348:g3596.

[full text on-line]

Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study
Rapid Response

by Gregory E Simon, Christine Lu, and Stephen Soumerai

British Medical Journal. 2014 348:g3596.

[full text on-line]

… Nevertheless, we must acknowledge that psychotropic poisoning is an imperfect proxy for suicide attempt and that use of this proxy measure might reduce the sensitivity of our methods. But this proxy measure is preferable to use of cause-of-injury codes in settings where use of those codes varies over time [precluding any valid time series analysis].

They want us to argue with their pretty graphs:

I don’t care to enter that argument because I don’t accept that the graph is related to the question at hand – because it isn’t. Again, end of story. I was tempted to argue with their analysis after removing their imputed lines from the graph. I’m not convinced that a straight line isn’t a better fit than their fancy quadratic quaisi-experimental fitting, particularly if you remove the last data point [that creates something of an optical illusion]. But I realized that line of criticism is just my bias engaging their flawed study. As I said previously in our own eyes…:

If someone actually did a non-jury rigged study that said that the black box warning is wrong, I wouldn’t change a single thing in the way I personally do things. David Healy says why best when he talks about getting doctors to "doubt our own eyes." See Akathisia once, a dramatic change in personality and the aggression that comes with the drug, that then disappears when the drug is withdrawn, and you’re on alert. See it the second time and that’s enough for this old man. It might as well be an epidemic. And given the fact that I’m an infrequent prescriber, that I’ve seen it often enough makes it real for me. I would bet it’s even under-reported because the patients stop that drug and don’t go back to see that doctor. I’ve prescribed SSRIs to adolescents and young adults infrequently, and only when I’ve said my spiel and am comfortable that I and competent others can keep close tabs. I can’t imagine anything ever changing that. There have been some successes, some failures, and much indifference. So I’m glad the black box warning slowed down the accelerating rate of prescribing – even in an HMO. And what I’ve seen with my eyes trumps epidemiology on large datasets.

Gregor Mendel was an Augustinian Monk in Moravia whose studies of plant inheritance brought such things into the realm of science. My sister’s blue eyes meant that both of our brown-eyed parents carried recessive blue-eye genes. The postman was out of the picture. Mendel’s schemes of inheritance were like that – very precise statistical predictions based on dominant genes. Things stayed pretty clean through Watson and Crick’s images of the double helix DNA structure, even Nirenberg’s nucleotide code sequences. But then things got out of hand…

The Human Genome Project was completed in draft form in 2000, and declared finished in 2003. With that, they left most of us mere mortals in the dust with their volumes and volumes of books filled with Cs, As, Ts, and Gs running on towards the end of time. And so much for pea plants, eye color, dominance, etc. It starts with a gene being "a locatable region of genomic sequence, corresponding to a unit of inheritance, which is associated with regulatory regions, transcribed regions, and or other functional sequence regions" and complexifies geometrically from there.  We thought it would be easy, but that was just a dream some of us had [as a kid, I set out to count the stars too].

Biological insights from 108 schizophrenia-associated genetic loci

by the Schizophrenia Working Group of the Psychiatric Genomics Consortium

Nature. 2014 511:421–427.

[full text on-line]

Schizophrenia is a highly heritable disorder. Genetic risk is conferred by a large number of alleles, including common alleles of small effect that might be detected by genome-wide association studies. Here we report a multi-stage schizophrenia genome-wide association study of up to 36,989 cases and 113,075 controls. We identify 128 independent associations spanning 108 conservatively defined loci that meet genome-wide significance, 83 of which have not been previously reported. Associations were enriched among genes expressed in brain, providing biological plausibility for the findings. Many findings have the potential to provide entirely new insights into aetiology, but associations at DRD2 and several genes involved in glutamatergic neurotransmission highlight molecules of known and potential therapeutic relevance to schizophrenia, and are consistent with leading pathophysiological hypotheses. Independent of genes expressed in brain, associations were enriched among genes expressed in tissues that have important roles in immunity, providing support for the speculated link between the immune system and schizophrenia.

This genome wide association study revealed 108 different loci where variations were associated with schizophrenia; 83 of these had not been reported previously. Note, these are not “108 genes for schizophrenia.” These are areas of the genome where variations in sequence are associated with schizophrenia. Most of these are not in or even near genes. And any one of these 108 regions contributes only a tiny fraction of risk in the population…

If my name were among the army of authors [302 total] on this study, I’d be proud too. They strengthened the case for a strong genetic loading in Schizophrenia [though most of us already accept that formulation]. Their large study contains variations found in previous studies [confirmation]. They’re intrigued by the regions being near areas already implicated in Schizophrenia research. And I expect the wheels are turning for the next steps based on these findings. Steven Hyman at the Stanley Institute is no doubt beside himself thinking about the coming $650 M from Mr. Stanley and Tom Insel is pretty excited too.

In my understanding of things, this is light years this side of finding a/the cause for Schizophrenia, much less a treatment. But it’s undoubtedly going in the right direction. To my way of thinking, it strengthens the case that there [are][is a] biological [causes][cause] to look for. But in terms of right now, it in no way dissuades me from the point of the last post. Those currently afflicted need our help and aren’t getting what they need. Not one of the chronic psychotic people alive right now is going to be helped by these findings, and they desperately need a lot more help than we’re giving them – in our lifetime – and in their lifetimes…

Director’s Blog: Mapping the Risk Architecture of Mental Disorders

NIMH

By Thomas Insel

July 22, 2014

It’s difficult to overstate the impact that genomic medicine is having on biomedical research and practice. For cancer diagnostics, rare disease therapeutics, and fields like microbiomics and infectious diseases, the advent of cheap, fast, precise genomic sequencing has been a game changer. What about mental disorders? There has been a lot of hype about genomics revolutionizing diagnosis or treatment of mental disorders, but is there any real hope that the kind of advances that have helped patients in the rest of medicine will help people with autism or schizophrenia or mood disorders?

The history of psychiatric genomics has been, until recently, disappointing. The search for candidate genes—such as those, like the serotonin transporter gene, suspected to be contributors to risk because of their role in medication response—led to many papers but few replications and no actionable findings. Unbiased scans of the whole genome were challenging because there is so much variation in the genome, most of which is unrelated to risk or resilience. To detect a signal from all of this background noise, one would need many thousands of samples. Over the past five years, as the field realized the need for larger numbers of samples, investigators from around the world have worked together to share results in the hope of attaining the statistical power needed to find variants associated with schizophrenia or autism. New findings demonstrate that sharing data does indeed lead to exciting results.

A report in Nature this week from the Psychiatric Genomics Consortium, a team of investigators in more than 80 institutions across 25 countries, looks at common variation (variation present in 10 percent of the general population) in nearly 37,000 cases of schizophrenia and over 113,000 controls. This genome wide association study revealed 108 different loci where variations were associated with schizophrenia; 83 of these had not been reported previously. Note, these are not “108 genes for schizophrenia.” These are areas of the genome where variations in sequence are associated with schizophrenia. Most of these are not in or even near genes. And any one of these 108 regions contributes only a tiny fraction of risk in the population. Nevertheless, this is a major step forward in describing the genetic risk for schizophrenia…

While we chase the receding holy grail of future basic science breakthrough, we are shamefully neglecting the needs of patients who are suffering right now. It is probably on average worse being a patient with severe mental illness in the US now than it was 150 years ago. It is certainly much worse being a patient with severe mental illness in the US as compared to most European countries. Access to community care and decent housing is deteriorating; hundreds of thousands of psychiatric patients are homeless or in prison…

Let us hope we don’t short-change our grandchildren, sixty years from today, by failing to invest in the long-term promise of more effective diagnostics and therapeutics for mental disorders.

I’m not going to bother to summarize what he said in that post. I’ve already done that [the first Lemming…], but the point is that he blew them off. That’s what he always does. He presents both sides in such a way to give the impression that he’s being like Solomon, but he doesn’t cut the baby in half. He keeps it all for himself and his dreams and doesn’t change gears [the most recent example of that technique was in his Are Children Overmedicated?]. So long as Dr. Insel remains in his position, the NIMH will continue with its monocular focus on the narrow window of his neuroscience interests and many of our severely ill mental patients will continue to live in whatever dark spaces they can find…