A Psychiatrist’s Prayer

April 9, 2009
Jerold J. Kreisman, MD

Volume 26, Issue 4

Lord, protect me from all the institutions that want to guard me from harm-Congress, PhRMA, academics, journal publishers, and even my APA. They fear I will be brainwashed. They fear-heaven forefend- I may use drugs “off-label.” I hesitate to inform you-it’s too late! I already prescribe medications offlabel, and I do it every day.

Lord, protect me from all the institutions that want to guard me from harm-Congress, PhRMA, academics, journal publishers, and even my APA. They fear I will be brainwashed. They fear-heaven forefend- I may use drugs “off-label.” I hesitate to inform you-it’s too late! I already prescribe medications offlabel, and I do it every day. (Yes, every day.) And most talented psychiatrists I know do too. But we do it not because we have been brainwashed but because such approaches sometimes work in treatment-resistant patients. And that is what makes our profession interesting and fun- helping some of the more difficult-to-treat patients.

Concern that pharmaceutical companies will inordinately influence doctors has led to such interference in medical education that we are left with the most bland and usually useless information. Industry reports have been so thoroughly vetted by company lawyers that all I learn is that a new drug is better than placebo and that minimal doses may work for most patients, thus justifying managed care companies from approving higher doses when appropriate. Frankly, the most valuable published information for me comes from case reports, anecdotal descriptions, and brief articles that describe innovative treatment approaches, including offlabel experiences.

Yes, pharmaceutical reps might bring information that causes me to try their drug, but if I don’t find it helpful, I won’t continue to use it. I resent the elitist position espoused by APA leadership, academics, and journal publishers, who accept industry money but fear its influence on us hapless practitioners in the field. Most of us (granted not all, but still most) are smart enough and ethical enough to metabolize information, even-horrors!-to evaluate off-label information appropriately. I also pray that we are at least as smart and as ethical as our congressmen, who can withstand the influences of major lobbyists but who are concerned that a labeled coffee mug and a free pizza may cause me to abandon my Hippocratic Oath. Attempts to protect us have only interfered with our goals to accumulate more clinically useful information for the benefit of our patients.