{"id":25524,"date":"2012-08-04T13:18:08","date_gmt":"2012-08-04T17:18:08","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=25524"},"modified":"2012-08-04T16:36:57","modified_gmt":"2012-08-04T20:36:57","slug":"in-the-name-of-ethics","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/08\/04\/in-the-name-of-ethics\/","title":{"rendered":"in the name of ethics&#8230;"},"content":{"rendered":"\n<div align=\"justify\">In June 2011, Dr. Marcia Angell, former editor of the New England Journal of Medicine, reviewed three books in the New York Review of Books:<\/div>\n<ul>\n<li>\n<div align=\"justify\"><u><strong><a target=\"_blank\" href=\"http:\/\/www.amazon.com\/gp\/product\/0465022006?ie=UTF8&#038;tag=thneyoreofbo-20&#038;linkCode=as2&#038;camp=1789&#038;creative=9325&#038;creativeASIN=0465022006\"><font color=\"#200020\">The Emperor&rsquo;s New Drugs: Exploding the Antidepressant Myth<\/font><\/a><\/strong><\/u> by Irving Kirsch<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><u><strong><a target=\"_blank\" href=\"http:\/\/www.amazon.com\/gp\/product\/0307452417?ie=UTF8&#038;tag=thneyoreofbo-20&#038;linkCode=as2&#038;camp=1789&#038;creative=9325&#038;creativeASIN=0307452417\"><font color=\"#200020\">Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America<\/font><\/a><\/strong><\/u><em> <\/em>by Robert Whitaker<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><u><strong><a target=\"_blank\" href=\"http:\/\/www.amazon.com\/gp\/product\/141659079X?ie=UTF8&#038;tag=thneyoreofbo-20&#038;linkCode=as2&#038;camp=1789&#038;creative=9325&#038;creativeASIN=141659079X\"><font color=\"#200020\">Unhinged: The Trouble With Psychiatry&mdash;A Doctor&rsquo;s Revelations About a Profession in Crisis<\/font><\/a><\/strong><\/u><em> <\/em>by Daniel Carlat<\/div>\n<\/li>\n<\/ul>\n<div align=\"justify\">Her reviews were, in and of themselves, a strong critique of psychiatry over and above the already critical books she was reviewing:<\/div>\n<ul>\n<li>\n<div align=\"justify\"><u><strong><a target=\"_blank\" href=\"http:\/\/www.nybooks.com\/articles\/archives\/2011\/jun\/23\/epidemic-mental-illness-why\/\"><font color=\"#200020\">The Epidemic of Mental Illness: Why?<\/font><\/a><\/strong><\/u><\/div>\n<\/li>\n<li>\n<div align=\"justify\"><u><strong><a target=\"_blank\" href=\"http:\/\/www.nybooks.com\/articles\/archives\/2011\/jul\/14\/illusions-of-psychiatry\/?pagination=false#fn-1\"><font color=\"#200020\">The Illusions of Psychiatry<\/font><\/a><\/strong><\/u><\/div>\n<\/li>\n<\/ul>\n<div align=\"justify\">Now, a year later, Dr. John Krystal, President of the <strong><font color=\"#200020\">American College of Neuropsychopharmacology<\/font><\/strong>, has written a response:<\/div>\n<ul>\n<li>\n<div align=\"justify\"><a target=\"_blank\" href=\"http:\/\/www.acnp.org\/resources\/articlediscussionDetail.aspx?cid=66d1c1bf-7c40-4af9-b4f5-a3856fe1b5ba\"><u><strong><font color=\"#200020\">Dr. Marcia Angell and the Illusions of Anti-Psychiatry<\/font><\/strong><\/u><\/a><\/div>\n<\/li>\n<\/ul>\n<div align=\"justify\">In his opening paragraph, Dr. Krystal summarizes Dr. Angell&#8217;s criticisms:<\/div>\n<blockquote>\n<div align=\"justify\"><sup>Dr. Marcia Angell, a former editor of the New England Journal of  Medicine, used the platform of book review to criticize the field of  psychiatry for issues that have long been recognized within our field  and are thus targeted by current research:&nbsp; psychiatric diagnoses are based on symptoms rather  than pathophysiology, our treatments are insufficiently effective,  newer medications have provided limited [if any] benefit over older  medications, <strong><font color=\"#990000\">the pharmaceutical industry has had inappropriate  relationships with individuals and organizations within our profession<\/font><\/strong>,  there are problems in access to psychosocial treatments for psychiatric  disorders, psychiatrists prescribe medications to treat symptoms rather  than correcting known biological abnormalities, our understanding of the  neurobiology of psychiatric symptoms is limited, and there are not  objective biomarkers to guide diagnosis or to match individual patients  with particular drugs.<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">I&#8217;ve linked the articles above. I&#8217;ll not go through them in any detail. Dr. Krystal&#8217;s response goes point by point, and is universally defensive. Its tone reminds me of the response of the APA President, Dr. Alan Schatzberg, to Dr. Allen Frances&#8217; initial article about the DSM-5 &#8211; almost a <em>how dare you?<\/em> I doubt there&#8217;s anything in it that would change the mind of any critic on any point. There are a few pieces of Krystal&#8217;s response that deserve special comment. <\/div>\n<p align=\"justify\">In his introduction, he lists Dr. Angell&#8217;s criticism that &quot;<em>the pharmaceutical industry has had inappropriate  relationships with individuals and organizations within our profession<\/em>,&quot; an understatement at best. In fact&nbsp; it could be reversed for emphasis, &quot;<em>individuals and organizations within our profession have had inappropriate  relationships with the pharmaceutical industry<\/em>.&quot; Dr. Krystal goes on to rebut Dr. Angell&#8217;s critique point by point, not quite reaching Dr. Schatzberg&#8217;s level of ad hominem nastiness [but coming close]. <strong><font color=\"#200020\">But he never mentions the pharmaceutical industry or the role conflict of interest has played in matters psychopharmacologic for decades. It&#8217;s a glaring omission.<\/font><\/strong> Prominent members of the ACNP were investigated by Senator Grassley; an editor of their Journal, Neuropsychopharmacology, was forced to step down over failing to reveal industry connections in a [ghostwritten] article; many of their members have been involved in the articles and programs that lead to the massive fines levied against the pharmaceutical companies for fraud [Study 329, TMAP, etc]. His silence on these points is deafening.    <\/p>\n<div>He ends with an argument known in the study of logical fallacies as a <a href=\"http:\/\/www.nizkor.org\/features\/fallacies\/special-pleading.html\" target=\"_blank\"><u><strong><font color=\"#200020\">special pleading<\/font><\/strong><\/u><\/a> [among others]: <\/div>\n<blockquote>\n<div align=\"justify\"><sup>She stigmatizes psychiatry, but fails to address the consequences of  stigma for psychiatrists and patients, including discouraging medical  students from entering psychiatry or dissuading  suffering people from seeking needed treatment.&nbsp; The absence of a  positive agenda in Angell&#8217;s essay was unfortunate.&nbsp; After all, what  value is there in critiquing psychiatry, if not to call for actions that  address the needs of psychiatric patients and society? Angell&#8217;s article  was an example of bad journalism.&nbsp; It is shocking that it was written  by a former editor of the New England Journal of Medicine, a journal  renowned for impartiality and rigor. Angell has written an  article filled with half-truths that would seem to call for society to  abandon psychiatric diagnoses, antidepressant medications, and  psychiatric neuroscience. Angell shows utter disregard for the negative  impact of each of these actions on individuals with psychiatric  disorders and society.&nbsp; She provides no alternatives to the status quo  or a constructive agenda that might ultimately speed the alleviation of  human suffering.&nbsp; Instead, she attacks the one clear path to better  diagnoses and more effective pharmacotherapies, translational  neuroscience.&nbsp; By stigmatizing a field progressing toward a scientific  foundation and by disparaging treatments that show signs of efficacy,  Dr. Angell&#8217;s facile criticism of psychiatry could do harm.&nbsp; Perhaps, in  this case, doing harm in the name of ethics is, to borrow a phrase from  Angell, a form of illusion.<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">In essence, he suggests that Dr. Angell&#8217;s criticisms or those in the books she&#8217;s reviewing are too destructive [implying destructive to patients]. I guess he&#8217;s suggesting that she should hold her tongue, should make psychiatry an exception to the rigor of scientific criticism because mental illness is hard, or because the projected future will be better. He even suggests that old parental adage, &quot;if you can&#8217;t say something nice, don&#8217;t say anything at all&quot; &#8211; and then puts the onus on Dr. Angell to come up with alternatives.<\/div>\n<p align=\"justify\">I&#8217;ll pass on fully commenting on this sentence, &quot;<em>Instead, she attacks the one clear path to better  diagnoses and more effective pharmacotherapies, translational  neuroscience.<\/em>&quot; It deserves a full hearing in its own right at some later date [in fact, on close reading that sentence actually makes no sense]. But I can&#8217;t pass on this phrase in the next one, &quot;<em>treatments that show signs of efficacy.<\/em>&quot; Treatments that &quot;<em>show signs of efficacy<\/em>&quot; don&#8217;t become the top selling drugs in all of medicine! And &quot;<em>treatments that <\/em><em>show signs of efficacy<\/em>&quot; should only be used in patients where that &quot;<em>efficacy<\/em>&quot; has been clearly demonstrated. Those &quot;<em>signs of efficacy<\/em>&quot; don&#8217;t trump adverse effects and events, <u>particularly<\/u> when they&#8217;re minimized, unacknowledged, or actually hidden. As a <em>for instance<\/em>, there&#8217;s a whole literature about &quot;Treatment Resistance Depression&quot; that actually rests on the premise that the polyglot of patients diagnosed with the umbrella term Major Depressive Disorder <em>should<\/em> respond to anti-depressants, and if they don&#8217;t, they fall into a special case and need some other biological treatment [eg STAR*D and CO-MED]. That doesn&#8217;t sound like &quot;<em>signs of efficacy<\/em>&quot; to me. It sounds like &quot;<em>so efficacious that non-response is the exception.<\/em>&quot;<\/p>\n<p align=\"justify\">I found the three books reviewed by Dr. Angell as well as her own comments painful too. But her synopsis of the course of events is an accurate accounting of the major trend in psychiatry over the last twenty-five years as I&#8217;ve experienced it. I was one of those &quot;talk therapy&quot; people she mentions, and her criticisms weren&#8217;t aimed directly at me. Yet it was painful, first, because I&#8217;ve felt many of the criticisms she makes of the state of the specialty and have felt impotent to do anything about the course of events she describes. And secondly, some of the people in the field of biological psychiatry are right-thinking, solid scientists working in a very hard corner of the medical world &#8211; taking an undeserved hit because of the gross misbehavior of others. But I found the comments from Dr. Krystal much more painful than either the books themselves or even Dr. Angell&#8217;s reviews. Neither his attack on the critics nor his pleas for help have anything to do with the facts. Psychiatry has dramatically overplayed biology in general and the efficacy, safety, and breadth of indications for the current medications in the specific, fostering the illusion of a knowing unmatched by knowledge. And a significant number of the scientists in the audience at any given ACNP meeting have actively participated in grossly corrupt science, unacceptable conflict of interest, and collusion at various levels with the drug-makers who profited wrongly from the phenomenal sales [as did the scientists themselves]. <\/p>\n<div align=\"justify\">By failing to address and rectify the central thrust of Dr. Angell&#8217;s indictments, the <strong><font color=\"#200020\">American College of Neuropsychopharmacology<\/font><\/strong> becomes part of the problem itself, when it&#8217;s in a position to become part of the solution. There&#8217;s a lot more to leadership that sticking up for the team. Dr. Krystal ended his comments with, &quot;<em>By stigmatizing a field progressing toward a scientific  foundation and  by disparaging treatments that show signs of efficacy,  Dr. Angell&#8217;s  facile criticism of psychiatry could do harm.&nbsp; Perhaps, in  this case,  doing harm in the name of ethics is, to borrow a phrase from  Angell, a  form of illusion.<\/em>&quot; I have absolutely no idea what he meant by that, but I have a feeling that it&#8217;s an amazingly misguided comment. <\/div>\n","protected":false},"excerpt":{"rendered":"<p>In June 2011, Dr. Marcia Angell, former editor of the New England Journal of Medicine, reviewed three books in the New York Review of Books: The Emperor&rsquo;s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-25524","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25524","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=25524"}],"version-history":[{"count":31,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25524\/revisions"}],"predecessor-version":[{"id":41719,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25524\/revisions\/41719"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=25524"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=25524"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=25524"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}