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Monday, 23.10.2017

Barry Blackwell: Corporate Corruption in the Psychopharmaceutical Industry

Mark S. Kramer’s response to Barry Blackwell’s reply to Mark Kramer’s comments

(Addendum: Please note that Barry Blackwell originally commented on my very first draft – the one I hastily submitted to INHN for what seemed to be its September 29th deadline. Upon learning that was not the drop-dead date, I requested and readily received an opportunity to clean up my draft with which I had not been very happy (in terms of flow, logic, critical omissions, and a general quirkiness,) I did this without input from any other party or network.  In the meantime, Barry commented on my first draft.  Without benefit of reviewing my final version, he then appropriately added an addendum in which he addresses some of the revisions within my second draft.  All of this now seems to be in order, and I have every reason to be happy with the process, and with no need to respond to his fine addendum! I hope he is happy, as well.)    

I treasure Barry Blackwell’s response to my long-winded commentary.  I was inspired on a number of counts: 1) Barry’s response is a role model in humility, 2) his reminder that he and I have similar backgrounds, have embraced similar viewpoints, and that these span the generation gap, 3) he allowed my passion to exist non-judgmentally, and 4) he actually read the sprawl!  To put things right, I’d like to clarify a few issues that Barry raised.  

Biological psychiatry as a discrete biological discipline

“Mark defends its integrity as a discrete discipline, is somewhat dismissive of psychosocial approaches and is concerned about disparagement by the anti-psychiatry movement. While I share this latter concern, I view biological psychiatry as part of a biopsychosocial matrix in the understanding and treatment of psychiatric disorders that is consistent with first person accounts by the pioneers . . .”

No matter its state of maturation, the biological portion of psychiatry needs to be practiced within a rational psychosocial framework.  The psychosocial framework, however branded, is sadly disappearing from much of medicine and surgery. I regard it as a requirement for optimal results in each sub-specialty of medicine - no more or less spanning from psychiatry to medical oncology.   To clarify:  For what it’s worth, reductionism to biology alone in Psychiatry or any other medical specialty (including surgery!) is just plain bad medicine.   

Far from wildly dismissing psychosocial factors as contributing to etiology or practicing (or addressing) them as treatment, I nevertheless do unimaginatively question whether particular brandings of psychosocial practice warrant consideration as specific, needed, or sufficient for diagnosis and treatment.  The control groups that could provide data for at least determining specific efficacy of non-drug/device interventions (on their own or synergistically with drugs/devices) are lacking or are just are not persuasive. 

My own experience suggests that psychosocial components of treatment are beneficial, even crucial, but likely do not warrant specific branding.    Mine is merely a personal belief awaiting scientific scrutiny, more than already afforded. To that end, I have earnestly plunged into the literature on control groups in CBT and the legion of non-medical interventions of Psychiatry /Psychology.  My belief is also formed by personal apprenticeships in general medicine (and in psychiatry [happily with pioneers of behavioral, cognitive, group/family therapies, and psychoanalysis {the latter which I received and ‘finished’ as part of training}).  

Attention, compassion, and a genuine ‘getting to know patients as whole people’ are common to all psychosocial practices with which I am familiar.  Far from the mere benefits of placebo expectation, these practices seem to enhance compliance (with either medication, drug holidays, toughing-out uncertainty, and repeat appointments), intrinsically offer some hope, consolation, make possible negotiation and acceptance of tough-love/advice, and provide a reassuring anchor for patients who’d be otherwise bobbing in turbulent seas. Much the same can be said the way a prescription of a psycho-pharmaceutical or placebo pill is offered.  Unfortunately, sessions for medication assessment and adjustment are way too short, as reimbursed, for any psychosocial repartee to flourish substantially.

As the pathophysiology (-ies) for each main syndrome in biological psychiatry become known, I do shamelessly envision biological psychiatry as initially becoming a discrete non-gamed biopsychosocial medical discipline, just like any other.  Then, with history as our guide (e.g., tertiary syphilis, Lyme disease, Irritable Bowel Disease, Gastric Ulcers, Thyroid disorders, etc.) biological psychiatry will be absorbed piecemeal into other disciplines, e.g., infectious disease, immunology, neo-endocrinology etc. In other words, until we have biomarkers for our most alarming behavioral syndromes, Psychiatry will continue ingloriously to function as a pay-toilet for medicine’s behaviorally tainted idiopathic syndromes.

The term - “biopsychosocial” – when it is invoked as a model for diagnosis and treatment in Psychiatry – conveys a most annoying compromise.  My view owes to an absence of persuasive data on the comparative efficacy of psychosocial interventions. Given the limitation of devising bullet proof talk-therapy controls, and as qualified,  pioneers and neophytes alike still lack persuasive data on 1) whether psychiatric psychosocial methods are any more specific/ effective than our local bartenders’, priests’, mentors’, friends’ ears and counsel, 2) thresholds upon which psychosocial methods (in terms of duration, frequency and type) should be supplemented with biological approaches, and 3) determinates by which the relative emphasis for diagnosis and treatment must shift from psychosocial to biological per course and type of behavioral deviation.   If these considerations delineate our “biopsychosocial matrix”, then the “matrix” begs to be populated with data.  While practice of medicine is the art of applied science, unfortunately Psychiatry remains mostly art. 

It may not seem evident, but formulation of a treatment plan for a patient with a broken bone has much in common with that for one with a “broken pattern of behavior.”  Both require investigation of psychosocial components for diagnosis and treatment.  However, the “biopsychosocial matrix” of Orthopedics generally includes a means to determine when a given bone break requires physical (bio) intervention, when psychosocial treatment alone would constitute either appropriate or mal- practice, or when both are required.   Except for our most disabling most stereotypical presentations, psychiatry lacks such objectivity.  In Orthopedics the biopsychosocial framework (“matrix”) is generally exactly actionable. For Psychiatry, it is not.  Is it asking too much for it to be so, someday?

Let’s innovate a Huxley style SOMA – Not!

 “Mark likens this to SOMA in Aldous Huxley’s “Brave New World” in which one character declares, “Hug me honey, drug me honey; half a gram of soma, hug me honey, drug me honey, till I’m in a coma.”

Love the lyrics, Barry!

 To clarify: Judging from sales of fluoxetine and its cousins, society seems to want/need a Huxley SOMA. Antidepressants are not it.  By no means have I suggested that this is a goal for innovation in psycho-pharmaceuticals. Of course, discovery of mood-energy elevating recreational drugs beyond caffeine, nicotine, amphetamines, methylphenidate, modafinil, L-DOPA, and ketamine (without physical addiction, tolerance, systemic AEs) for healthy individuals would be a controversially non-medical product, but nevertheless a triumph in neuroscience.  My concern is that upon beholding the huge market size of demoralized citizens of the world, industry may pursue this as a non-medical product. This they have already done with medicalized nootropics, hoping to generalize medical indications such as mental retardation, ADHD, neurodegenerative syndromes, or post traumatic brain injury to off label use as “SOMA” for our dysfunctional society.   Already it is a $billion market.   

Coincidental decline of antidepressant use and increase in recreational drugs

A [SOMA] . . . is hardly different from the street recreational drugs that Mark speculates might have triggered a decline in SSRI prescriptions.   

To clarify:  The theory is that as antidepressants have gone off patent, “happy pill marketing” has plummeted, and so has public adoration of fluoxetine and its cousins.   Once considered by some a type of “Huxley SOMA” for demoralization/dispirited unrest, people might be replacing their antidepressants with recreational drugs. It is hard to say, because prevalence of recreational drug use seems to cycle every ~20 years for unknown reasons.  Frankly, this political season provides data galore on why vast swaths of humanity are appropriately dispirited; why after the polls close in November, many will be hitting local taprooms or hooka-bars for group consolation - numbing of minds and hearts.  This, perhaps an appropriate short term fix on election night, is hardly a long term solution for a political depravity that consistently diminishes quality of life for most of “we the people.”   While our ‘Frank Underwoods” may wish such a solution, the effects of current political degeneracy on society requires some sort of revolution, not mitigation by psycho-pharmaceuticals or therapies.

Frank Berger, discoverer of meprobamate, the first anxiolytic, believed emphatically that medication was not a substitute for philosophical or psychotherapeutic interventions in treating the troubles of daily living. (See the review of his book, published posthumously in INHN Biographies).

Agreed, mostly.  As above, my question is whether treating troubles of daily living requires a licensed psychotherapist. (e.g., Dawes 1994; Furukawa et al. 2014) Has it been demonstrated that the latter helps improve one’s life any more than can a trusted friend, spiritual person, amateur masseuse, wine tasting group, or the neighborhood’s backyard BBQ philosopher?  Of course, myriad papers and books already claim that licensed therapists are required.  As the most derided and controversial medical discipline of all, Psychiatry cannot afford to be fooled by such consensus.    

I suppose people who cannot reach out to trustworthy buddies, or who burn them out, must hire “professional fellows” for their tune ups.  As to receiving problem solving advice or just the vetting of any confusing feelings/ thoughts, I’d sooner initially appreciate the wisdom of life-long friends, than qualified therapists. If not satisfying, then I’d not be opposed to vetting trained coaches or therapists.  

On some of my less than diplomatic comments

Mark still claims I was “seduced and became a publicist” for Whitaker.

Mea Culpa! (beating chest.)   I thought I may have missed something, but already my freight train was roaring along at full throttle.  It only seems appropriate to don a hair shirt while ingesting some phenelzine, a carafe of Chianti, Gorgonzola and Swedish gravlax on sourdough bread.   Indeed, you did crosscheck some of Whitaker’s embellishments with Fuller Torrey’s writings.  Darn! No disrespect intended to Barry, but as to Whitaker . . .   

Solutions to Government Aspect of Corruption

As you say a knowledgeable approach to government is critically needed to stem the corruption.   I just listed the branches.  About the ways to do so, I do not have a clue. You also presented a list of government targets as well as new allocation of public funds among them.  These suggestions do require analysis.  I am naturally tempted to dig in, but for practical reasons at this time I’m compelled to simply enjoy the forthcoming wisdom of those already undertaking to resolve this aspect of our quagmire. 

 

In closing

Thank you for your vote of confidence re my leading a New National Drug Evaluation Unit.  Based on the present NIMH multi-year plan and the deafening silence of NIMH in response to my comments on it, I think public service is not in my cards.   Dispassionately, I am neither sufficiently bright or sly to navigate that service.

         I too very much look forward to comments from colleagues on INHN.   Thanks. Barry, for a masterful stirring of the pot. 

 

References

Dawes, R. 1994. “House of Cards: Psychology and Psychotherapy Built on Myth.” JAMA: The Journal of the American Medical Association 272: 1465–1465.

Furukawa, T. A. et al. 2014. “Waiting List May Be a Nocebo Condition in Psychotherapy Trials: A Contribution from Network Meta-Analysis.” Acta Psychiatrica Scandinavica 130(3): 181–92.

 

Mark S. Kramer

November 24, 2016