Barry Blackwell: Pioneers and Controversies in Psychopharmacology, Chapter 19. The End of the Beginning: Beginning of the End? Corporate Corruption in the Pharmaceutical Industry.
Barry Blackwell’s reply to Max Fink’s comments
I appreciate Max Fink’s comments on how the manner in which corporate corruption in the psychopharmacological industry, and the Zeitgeist that enabled it, also exerted a malign influence on his own special area of interest and his exceptional contributions in the arena of induced seizures (ECT), making it “a pariah of neuroscience.”
With regard to popular acceptance, ECT got off to a difficult start. Introduced before the discovery of any of the modern psychopharmaceutical drugs or the muscle relaxants, and often given without anesthesia, its public debut in a popular movie (The Snake Pit) garnered a troubling image perpetuated by the Scientology movement even today.
Like ECT, all the new psychotropic drugs were discovered by serendipity, often abetted by “prepared minds,” and the next two decades (1950-1970) were spent in vain attempts to identify specific neurochemical or genetic etiologic explanations for their method of action and outcomes. This put the cart before the horse but, as Max notes, the quality of the enterprise was vastly improved by placing it in the hands of Federally funded Early Clinical Drug Evaluation Units (ECDEU) and away from industry. This policy was reversed in the mid 1970s when events documented in my original essay gave control back to industry.
Failing to discover innovative new compounds, industry switched its efforts from science to marketing, producing vast profits that were used to establish economic hegemony over lay, professional and academic organizations. The US Congress, as well, played its part with the lax drug regulatory legislation it passed. Complicit academics (KOL’s), bribed by industry, led to fraudulent research and widespread conflicts of interest disseminated among FDA advisory committees, Best Practice Groups and Journal Review Boards.
The conflicts of interest generated were glibly acknowledged but never penalized by academic institutions or professional organizations, thus irreparably fracturing the relationship and roles of academic psychiatry and industry (Ban 2006).
Contributing to this deteriorating scene is the insidious impact of the DSM system now in its fifth iteration. This system embraced a symptom-based diagnostic schema derived from “expert consensus” that implicitly denied the wisdom of nosology and epistemology of prior centuries. De facto, this allowed industry and complicit academics to link quasi-diagnostic entities to lucrative products. Meanwhile, hidden away among a plethora of symptoms in the modern category of “major depressive disorder” lay the oft-forgotten syndrome “melancholia” -- a time- honored biologically determined disorder for which ECT was the first effective treatment and retains that promise today.
Recently, the NIMH and the National Research Council attempted to intervene. In 2008 the NIMH ceased further funding of projects using the DSM system and imposed its own NIMH Research Domain Criteria (RDoC) (Insel et al. 2010), a system criticized for lacking a scientific basis (Weinberger, Glick and Klein 2015). In 2011 the National Research Council addressed this issue in TowardPrecision Medicine, but the NIMH already questioned its value (Insel 2014).
In the past several decades a dispiriting Zeitgeist has caused medicine to morph from a profession into a business in which health care has become a “for profit” product. Morale among physicians generally is low, more so in psychopharmacology which has all but disappeared as an academic discipline. The number and influence of psychopharmacologists in the ACNP is dwindling. If there is a glimmer of hope, perhaps it is in the domain of neuroscience. Only when we better understand the neuropathology and neurochemistry of the disorders can we begin to apply hypothesis-driven inductive research to find new cures - perhaps particularly so for ECT where understanding about how it works will lift the pall of disapproval under which it has lingered far too long despite the strenuous efforts of Max Fink and his colleagues. But this may only happen if and when there is government help in creating an adequately funded and ethically cleansed academic environment.
Ban TA. Academic psychiatry and the pharmaceutical industry. Progress in Neuro-Psychopharmacology & Biological Psychiatry 2006; 30; 429-41.
Insel T, Cuthbert T, Garvey M, Heissen R, Pine, DS. Quinn K, Sanislow C, Wang P. Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. Amer. J. Psychiat. 2010;167: 748-51
Insel T. The NIMH Research Domain Criteria (RDoC) Project: precision medicine for psychiatry. Am J Psychiatry 2014; 171:395-7.
National Research Council: Toward Precision Medicine; Building a Knowledge Network for Biomedical Research and the Taxonomy of Disease. Washington: National Academic Press; 2011.
Weinberger DR, Glick ID, Klein DF. Wither research domain criteria (RDoC)? the good, the bad and the ugly. JAMA Psychiatry 2015;12: 1161-2.
February 28, 2019