Mood Swings

A psychiatrist surveys the mind and the wider world.

by Dr. Nassir Ghaemi

Witch Hunt?

By Dr. Nassir Ghaemi on June 16, 2008 in Mood Swings

Another mainstream article makes the press about corrupt doctors taking pharmaceutical industry money. The June 8 New York Times reported on a US Senate investigation into poor disclosure of millions of dollars in income provided by pharmaceutical companies to Harvard child psychiatry researchers at Massachusetts General Hospital (MGH). Like Dr. Peter Kramer ("In Practice" blog), I too have carefully followed the work of the MGH research group, both for their research on childhood bipolar disorder (with which I agree in large part) and their research on ADHD in adults (with with I disagree in general). Regarding treatment, my own experience and research has tended to be opposite to theirs: I have found amphetamine stimulants (especially methylphenidate) and antipsychotics to be less effective and more harmful than they have reported. Has their optimism about medications been biased by their profits? Perhaps; perhaps not. There are plenty of profits to go around, and just as much can be made these days bashing medications as marketing them. Read More

Biases

Submitted by Lawrence Diller, M.D. on June 16, 2008 - 9:50pm.

Nassir:

Larry Diller here. I've read some of your work Nassir and while I respect your erudition I'm not always sure I understand your point or agree (for example your book attacking the biopsychosocial approach to mental health/illness -- I never quite got it but thought it might be a defense of the department of psychiatry at Harvard -- but I admit I may not have quite gotten it). Still, Nassir you appear to criticize the recent gaggle of books addressing the influence of the drug industry on American medicine. Note Nassir that Big Pharma runs ads on TV and magazines multiple times a day -- a so much greater influence on public opinion than these mostly academic tomes. Regardless of individual probity, the data is clear that industry funded studies tilt toward the pro-drug side of things. You raise very reasonable points about funding, research, incomes, capitalism etc.. But practically speaking doctors are in the process of losing their credibility with their close economic ties to the drug industry. This is a return to more than 100 years ago. I don't trust a Biederman study much any more and I'm on the front line depending on guys like you and Biederman to make things clearer. Anyway, I know I'm not always mainstream but I think I do represent some of the concerns of physicians on the front-lines with my position.

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Dear Larry:Many thanks for

Submitted by Dr. Nassir Ghaemi on June 19, 2008 - 11:16am.

Dear Larry: Many thanks for your comment. I agree that credibility is in question. I don't think the solution is simply to believe or disbelieve the research, or any particular researcher, but rather to critique that research, using understanding of scientific methods. Now I appreciate and agree that we as academics have not done a good and honest enough job of engaging in that kind of objective scientific critique. That is a profound responsibility that we need to take up. I also think, though, that every individual practitioner has a responsibility to read and understand science. It is not enough to read the abstract and conclusions, and then either believe or disbelieve based on pharmaceutical industry funding or the reputation of the researcher. The methods sections needs to be understood and analyzed. Obviously, the msot complex studies will be challenging, but most of this research is rather straightforward, and with one-tenth of the effort we spent learning histology in medical school, the average clinician can understand it. I am working on a book right now to try to translate this level of statistical knowledge to clinicians. I also agree that Big Pharma has the marketing advantage. But I don't think that the best response to the one-sided and biased advertisements of the pharmaceutical industry is to publish a slew of one-sided and biased anti-pharmaceutical industry books. Neither are credible. To me, the crux of much of this gets to how we understand science. Science is not about adversarial viewpoints that compete with each other, and in fact glory in such confrontation - as, say, in the law, or in the political theory of democracy (countervailing forces). In science, we actually believe there is a truth, and we need to find and speak the truth. This is not the same, by the way, as being "balanced", a phrase commonly used in our current debates about conflict of interest; one cannot be "balanced" about the truth: the truth is the truth. If I show in my research that lithium level of 5.0 will kill patients, it is not anyone's responsibility, nor at all appropriate, for others to try to do research that shows that a lithium level of 5.0 is safe. Unfortunately, much of our thinking about such matters is suffused with a cultural postmodernsim, with deeply held assumptions about the relativity of truth. (Daniel Dennett's lecture on Postmodernism and Truth is a good source on this: http://ase.tufts.edu/cogstud/papers/postmod.tru.htm). Part of what I am doing in my book, and in my critique of the biopsychosocial model, is to show how harmful such blithe eclecticism is to our field; where anything goes, we all end up either confused, or believing that there is no truth to the matter. And then it is easy for those with the finances and a special interest (whether the pharmaceutical industry, or managed care, or others) to influence the profession unduly. I'll plan other posts to spell these ideas out more. But in all this, I agree with your general point, though, that our profession has lost credibility due to our relations with industry.

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I enjoy your thoughts here,

Submitted by Gina Pera on June 24, 2008 - 5:26pm.

I enjoy your thoughts here, Nassir, and look forward to reading your book.

But I have to disagree with your last point. In my opinion, your profession has lost credibility due to widespread incompetence. This opinion is based, in part, from talking with hundreds of people who have pursued mental healthcare in the last eight years. It's also based on familiarity with protocols--and knowing how few docs follow them.

Thanks also to psychiatrists who "treat one molecule" without understanding that there is a body attached, we have a nation of people suffering needless side effects and swearing off medication forever. Medication that could enhance their lives tremendously.

These people largely can't believe that their highly educated physicians can be so inept (cognitive dissonance), so they blame the medication, pharma, and the researchers who develop the medications.

We've lost a few generations to this clinical ineptitude and likely a few generations more, if grandstanding politicians and psychiatrists who don't "get it" have their way. As long as ignorant people, including psychiatrists, keep playing into the hands of politicians whose campaigns are funded by insurance companies, we all stand to lose the marvelous advances that neuroscience has given us. And that would be a grave tragedy.

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Practices

Submitted by Vaughan on June 18, 2008 - 2:56am.

Hi there,

I think you are mistaken to focus on the issue of profit per se, as the criticism is largely about business practices and lack of transparency.

It is perfectly possible to be a profitable pharmaceutical company without burying data, manipulating outcomes, disease mongering, pressuring academic departments and off label promotion, which are widespread.

Furthermore, ghostwriting, giving soft money to researchers, advertising to consumers, influencing conference line-ups and giving gifts to doctors, are in my opinion, ethically dubious, but are made ethically unacceptable if the full extent of influence is not available to the public or other professionals.

A profit driven drug development system is clearly a powerful and important force in the advance of medicine, but it needs to be done ethically and transparently.

The recent press criticism of the Harvard researchers is not about payments, its about undeclared payments. Whether one wants to defend industry ties or not, I doubt anyone would defend lack of transparency in this area.

As an aside, I'm afraid your comments about 'socialised medicine' as a system 'cleansed from any capitalist basis' and without a 'profit motive' are way off the mark.

What I suspect you're referring to with references to the UK and Canadian health systems is essentially a socialised health insurance scheme. At least in the UK, services within the National Health service, and, of course, commercial companies that provide drugs and services, have to remain profitable or they cease to exist. The same issues apply.

All the best,
Vaughan

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I agree with your point

Submitted by Dr. Nassir Ghaemi on June 19, 2008 - 11:15am.

I agree with your point about the issue being nondisclosure but I also think the amounts are relevant: they are seen as a problem of excess profit, though perhaps not profit per se. My post was intended to bring out this kind of nuance. Even if such high profits are disclosed, the perception of bias would remain. Many agree now that disclosure by itself is simply not enough to address the problem of bias in relations with the pharmaceutical industry. Though this is not directly part of your comment, it seems to me that many critics have a problem with excess profit for academics in particular, and the pharmaceutical industry as well. I agree this is a problem. However, I wonder why we still apply it uniquely here. For instance, if a I write a anti-pharmaceutical industry book, and it becomes a best-seller, and I make millions, does it mean that my book is thus more biased than a similar book that does not sell well? Another example: if a researcher makes a discovery that leads to high profits for his university (such as millions produced by developing a new drug for HIV), is that research thereby to be deemed biased, compared to another researcher's work which produces no profit? I think tying more dollars to more bias is not logically correct, though I also agree that better, more transparent, more honest, and less marketing-oriented business practices should be demanded from the pharmaceutical industry, and that medical academics needs to limit and control its relations such that the profit motive does not play a central role in the academic world.

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Could you explain what you

Submitted by Gina Pera on June 24, 2008 - 5:44pm.

Could you explain what you mean here, please:

... I too have carefully followed the work of the MGH research group, both for their research on childhood bipolar disorder (with which I agree in large part) and their research on ADHD in adults (with with I disagree in general). Regarding treatment, my own experience and research has tended to be opposite to theirs: I have found amphetamine stimulants (especially methylphenidate) and antipsychotics to be less effective and more harmful than they have reported.

1. What do you disagree with in Biederman et al's approach to ADHD in adults? And what is your basis of disagreement?

2. You know that methylphenidate is not an amphetamine, right?

Thanks

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I will put up a new post to

Submitted by Nassir Ghaemi on June 27, 2008 - 1:18pm.

I will put up a new post to raise my concerns about overdiagnosis of ADHD and overuse of stimulants.

On your second question, though, I hear this all the time, as if to excuse methylphenidate as safe and untainted from the associations with amphetamines. The distinction is claimed that amphetamines are direct stimulants of dopamine receptors while MPH is supposed to block reuptake of dopamine and norepinephrine. Either way, the dopamine system is stimulated. For what it is worth, according to DrugDex, MPH is classified as "amphetamine-related" and MicroMedex says "the drug has similar pharmacological properties as the amphetamines." I don't think the claim that is just unrelated (and by implication safe) is correct. My posting soon will lay out its risks.

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NHS = lousy psychiatric care

Submitted by Gina Pera on June 26, 2008 - 9:34pm.

Vaughn wrote:

As an aside, I'm afraid your comments about 'socialised medicine' as a system 'cleansed from any capitalist basis' and without a 'profit motive' are way off the mark.

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Boy, is that the truth! As the leader of an international online support group for Adult ADHD, I can tell you that our members who deal with socialized medicine have a disastrously hard time finding competent care, much less good medications. And that's saying something, because it's difficult enough here, even in our large cities and even with good insurance.

In fact, members from the UK, Australia, and elsewhere often grow bitterly envious after learning about the success stories among the U.S. and Canadian members. Their NHS care providers mostly fail to acknowledge ADHD, much less treat it. They must chase down the few private-practice specialists and pay out of pocket for very expensive medications. Unfortunately, ADHD itself can be an impediment to accumulating wealth, so they often do without.