Worrying About Greed
Worrying About Greed
I’ve been deeply worried about corruption and greed in psychiatry for a long time. In reading the new book from Wendell Potter, formerly head of public relations at CIGNA, my worry has escalated into panic anxiety. Before discussing Potter’s work, let me review some of the widespread greed-related corruption of recent years.
• The most awful are the revelations about pharmaceutical company tankings of pharma-sponsored clinical trials with negative results. The dozens of exposes issued by journalists in recent years cannot possibly be reviewed here, but a nice sample list can be found here. Browse the links at your own risk; you might need antidepressants afterwards, if you still believe they work! The significance of this for practicing clinicians is that (excepting NIH sponsored clinical effectiveness studies), everything we thought we knew about drug efficacy must be questioned - in psychiatric practice and elsewhere.
• In large part due to this greed-motivated corruption of the scientific enterprise, a multi-pronged response had been initiated by Congress, in passing the 1997 Food and Drug Administration Modernization Act, which established ClinicalTrials.gov as a public-access registry for clinical trials, though on a voluntary basis. An effort to mandate public registration of clinical trials, the Fair Access to Clinical Trials Act in 2005, was never passed. Pharma can, and still does, tank negative studies.
• The International Committee of Medical Journal Editors (ICMJE) [www.icmje.org ] issued a statement in 2004 presenting their policy for a mandatory registration of clinical trial results before the first patient is enrolled, as a condition for ICMJE-compliant journals to consider publication. This and other features of the ClinicalTrials.gov effort are summarized here.
• A set of 14 recommendations for tightened conflict-of-interest rules for psychiatrists’ relationships with pharma was voted down by the APA assembly last year. The recommendations were drafted by an 11 member APA panel headed by former APA President and ethics leader Paul Appelbaum. Interestingly, it was younger psychiatrists who most strongly advocated for the recommendations.
• Psychiatric Times published a debate between Lisa Cosgrove, Harold Bursztajn, Darrel Regier, and David Kupfer concerning the role of pharma in influencing DSM-5 decisions.
One could go on, and many have, but I wanted to alert the Blog readers to Wendell Potter’s new book, Deadly Spin, which amounts to an insider’s expose of the very powerful industry influence not just on medicine but government as well. Potter goes beyond the facts of the nationwide lobby and propaganda efforts on the part of the medical insurance industry through describing the techniques he authored for industry. The primary focus of his discussion is the insurance industry’s systematic misinformation campaign regarding last years’ health reform bill; and the major target there was the (to the industry) dread public option (which would immeasurably aid the chronic mentally ill). Interested readers can get a short synopsis of Deadly Spin, as well as insight into why Potter decided to resign from CIGNA and pursue this expose, through Bill Moyer’s PBS interview. What is remarkable is that after all these years of secrecy, why should a courageous soul like Potter step forward now? (No doubt, spin persists in his own book, but Deadly Spin reads more like investigative journalism than PR.)
I can only worry about the behind-the scenes influence of pharma, and what kind of greed-motivated manipulation of “scientific” data is being promulgated by industry in the effort to shape industry-friendly diagnoses. DSM-5 authors are still subject to industry influence and biased interpretation of data. In the absence of DSM-IV-style comprehensive literature reviews and Source Books, the selection and interpretation of research to support DSM-5 categories is at the Work Groups’ whims. Denials of influence are not very convincing; show us the scientific rigor, please. We still don’t know what is going on behind closed Work Group doors, and all the DSM-5 draft indications point to the pharmaceutical market having another quantum-leap expansion in 2014 as new disorders are rolled out.
James:
Thanks for your comment. I think the only way to make some headway here is from grassroots interest from colleagues. Comments from readers?
- A much-needed call to action, John, thanks! The sad part for me--besides the issues you covered--is that most psychiatrists are getting up each day, going to work, and trying their best to help some very seriously ill and distraught individuals. Those who corrupt science and betray the public interest are also hurting each and every one of their colleagues who are doing the hard work of helping patients. And this, in turn, hurts our patients, as well. ---Ron Pies
Brillent piece. My husband, who works in the pharmaceutical industry, agrees with you whole heartedly and is presently slamming his head into a wall to kill the pain from this shameful state of affairs. This is why he is quitting science and going into Regulatory Affairs.
Dr. Sadler: I agree with your assessment; however I am wondering why you gave the NIH-funded studies a 'pass.' And when did you first become aware of the corruption and greed in psychiatry? See http://oig.hhs.gov/oei/reports/oei-03-07-00700.pdf
It is a pity that this piece identifies the 'greed' as intrinsic to Psychiatry; the willy nilly embrace of psychopharmacology as psychiatric practice is as troubling as Big Pharma's corruptions and insurance benefit arbitrary criteria.
After the appalling front page NYTimes article about Dr. Levin converting to lucrative 15 minute med management x 40/day from what he claimed was an impoverishing psychotherapy practice (it is hard to believe such a shallow fellow was competent at true psychological work!).
As psychiatry has become dominated by the med hype (only 11% of patients receive psychotherapy) - it seems evident that this is both easier and pays better. It also suggests that many psychiatrists are actually unable to provide effective psychotherapy (which goes beyond 'supportive' advice giving and requires more disciplined study, consultation and updating from what has become minimal residency training). The term 'talk' therapy trivializes a highly skilled clinical discipline- which ranges from meticulous relational analysis to CBT.
The absence of most MDs' competence to provide the best evidence-based care (psychotherapy and medication) is a travesty in modern psychiatry and clearly has become an enabling, colluding factor in the collapse of ethical practice and the rationalization that supports reflexive prescription of costly pills with equivocal benefits in eutherapeutic sessions.
The corruption will continue until we psychiatrists present to the pharmaceutical industry a formal, articulated and fully scientific model of mental disorder. In the absence of this, the sine qua non of any field claiming to be science, the pharmaceutical industry will continue to pay the piper and psychiatry will have to dance to any tune the industry calls. The notion that mental disorder just is a biological disorder of the brain automatically gives the pharmaceutical industry a stranglehold on psychiatry's intellectual development - or lack of development, as the case is.
From Ron Pies MD-- I suppose I am a bit more sanguine about psychiatry's humanistic inclinations than some of my colleagues, and perhaps more hopeful that we will find our way out of the present crisis--notwithstanding the dispiriting New York Times portrait of one overwhelmed psychiatrist. I discuss that article in detail in my own blog on this website:
http://www.psychiatrictimes.com/display/article/10168/1819880
I would also like to clarify the "11%"figure mentioned in reference to psychotherapy. The figure is derived from the study by Mojtabai & Olfson [Arch Gen Psychiatry. 2008;65(8):962-970] and refers to the percentage of psychiatrists who provided psychotherapy to all of their patients. Thus, it does not reflect the percentage of patients in a psychiatric practice receiving psychotherapy. Furthermore, the piece in the NY Times fails to note (again, based on the Mojtabai & Olfson data) that over 59% of psychiatrists are providing psychotherapy to at least some of their patients.
Other data from Reif et al show that about two-thirds of cases in a managed care psychiatric practice receive some type of psychotherapy, and 30% of psychiatrist visits involved use of both psychotherapy and medication, on the part of the psychiatrist [Psychiatr Serv. 2010 Nov;61(11):1066-8]. Thus, the report in the NY Times underestimated psychiatrists' provision of psychotherapy, at least in some settings.
My own view is that a combined approach is often the most effective for severe and refractory conditions. However, I would certainly like to see greater use of psychotherapy on the part of psychiatrists, as a first-line treatment--especially in the less severe presentations we often see. --Ronald Pies MD
Thank you for this highly relevant piece Dr. Sadler.
You are not alone in your worry.
The time is long over due for psychiatry to begin to work earnestly towards undoing the damage this has caused, and applying our own unbiased medical knowledge towards helping our patients and furthering the field.