Thursday, September 22, 2011

Psychiatry on the Dock: A Case to Answer

This is a very quick slap-together piece. I just came across a blog piece on Psychology Today, posted by my friend John Gartner, author of “The Hypomanic Edge.” The title to his piece posed this provocative question: “Has Psychiatry Been Corrupted Beyond Repair?

The evidence weighs heavily on the side of yes. According to Dr Garter, “no industry has been as systematic nor as successful as drug companies in infiltrating the knowledge base concerning their products.”

Imagine this, Gartner asks: “What if every scientist studying global warming was paid by Exxon?” Eighty percent of academic psychiatric research studies, he says, are funded by Pharma.

Gartner’s litany is a familiar one: Marketing disguised as science, outright fraud, suppressed negative evidence. Even those who practice psychiatry, says Dr Gartner, have been bought out. Back when Dr Gartner got out of graduate school, psychiatrists were earning 50 percent more than psychologists. Now, he says, the difference can be as much as 1000 percent.

The 1000 percent refers to a handful of academic superstar psychiatrists who are very handsomely rewarded by Pharma to lend credibility to its fake research. But the rank-and-file don't make out badly, either. A Medscape survey I noted in a previous piece reported that psychiatrists in the US average $175,000 a year, about twice as much as PhD psychologists at $82,000 annually (according to and three-to-four times the MSW range at $44,000-$65,000).

But a psychiatrist seeking to make an average income needs to devote his entire practice to 15-minute meds checks. Actually taking the time to listen to patients doesn’t pay the bills. And it doesn’t make for the good practice of medicine, either. Said Nassir  Ghaemi (who needs no introduction here) on Medscape:

Identifying diseases that underlie symptoms requires longer and more careful evaluations than I fear the average psychiatrist gives the average patient.

Earlier this week, a long-term reader emailed me wanting to know if there was an intelligent counter-argument to Robert Whitaker’s “Anatomy of an Epidemic.” I told her no. Here is part of my reply:

The bottom line is psychiatry has not made a single dent in Whitaker's thesis. This is a very severe indictment on psychiatry. Right now, Whitaker makes a much stronger case for meds making us worse than psychiatry can for making us better. If psychiatry cannot make a credible case for itself, then psychiatry deserves to become extinct as a profession.

This is a far cry from saying Whitaker is correct. But Whitaker has very clearly made what they call in British law “a case to answer,” a strong prosecutorial argument with good quality evidence. Psychiatry’s silence is both foolish and damning.

In response to a series of well-publicized scandals, psychiatry has passed tighter rules regulating professional conduct. But we need to face facts, argues Gartner. “Psychiatric research has become corrupted, not around the margins, but at its core.” Findings are no longer credible. “We don't know, and can't know, if the pill psychiatrists are pushing today is the next Neurontin, or worse.”

Neurontin, you may recall, was marketed by Warner-Lambert (since incorporated into Pfizer) as an off-label bipolar med. The drug was a dud. Warner-Lambert knew it and so did Pfizer. Pfizer agreed in 2004 to pay $430 million in fines, but this was merely the cost of doing business. The year before, according to the Wall Street Journal, 90 percent of Neurontin’s $2.7 billion in sales came from off-label uses.

Dr Gartner tells us that psychiatrists regard the Neurontin story as old hat. Off course Neurontin is useless for bipolar, one psychiatrist dismissively told Dr Gartner. Then he cheerfully added, “but it works for anxiety.”

Really? asks Dr Gartner. Says who?

And the beat goes on.


Bipolar Test said...

I really have a good time reading all this posts here. Keep on posting more of this.

Smitty said...

You put it into words in a way that is so clear to me.

I also want to know what it is like for a psychiatrist who does not prescribe medications the way the insurance companies want them to... or .... when the psychiatrist finds medications do not work for a person on public assistance. What will Medicaid pay for then?

John McManamy said...

Hey, Smitty. I don't have firm answers and the situation has lots of nuances. The best practice of medicine often involves off-label uses. The company that made Tegretol, for instance, never bothered to seek an FDA indication for bipolar. It only became FDA-approved when a different company sought approval for the generic version. Heaven help if "reformers" were successful in banning off-label uses.

An enlightened psychiatrist looks beneath the diagnosis to what is really going on (lack of energy? stressed out?) and prescribes accordingly, then may just stick in a diagnosis in order to get paid.

Medicaid varies from state to state. My understanding is a limited round in talking therapy is usually available, but basically you're on your own if meds don't work, and they don't work for a lot of us. Good luck trying to get ECT with Medicaid.

Smitty said...

Yes, meds don't work for a lot of us. And sometimes sanity returns, and the medications are what is credited.. when in our guts... (or our gut-brains?) we know it is time to fly free and really find out.

And I love this irony now. That a doctor can look at me doing well and totally give credit to the medications! When the real thing is that I have finally learned to trust MYSELF! He he!

John McManamy said...

Hey, Smitty. And if the meds make you worse or poop out, YOU get the blame. We never get credit. Going off meds is a risky business, but so is any decision involving staying on meds. Every decision carries risk. An enlightened doc can really help, but they are so few.

Moira said...

Thank you for this blog entry with a link to Dr. Gartner's blog. I didn't know he was at Psychology Today.

Amen to your response in the comments section that enlightened docs can really help. How does one go about finding an enlightened doc? Craig's list? eBay?

I would try Dr. Jim Phelps website first:

All the best,

John McManamy said...

Hey, Moira. Dr Phelps is one of the enlightened ones. His book goes against conventional wisdom, but is right in line with other enlightened docs such as Drs Goodwin and Ghaemi and Akiskal.

Probably your best source of finding an enlightened doc is through your local DBSA, but I need to qualify this. No one doc can please all. The doc that someone just fired could be the one that is a godsend to you.

Also, some people are very lucky to have an academic superstar as their doc, but these docs are virtually unavailable except on a once-only consultancy basis.

So you have to shop around on the streets, hopefully not through eBay. eBay is more for finding a wife or husband. :)

But the word does get around. There is one doc here in San Diego who has an awful lot of DBSA patients.

I would strongly suggest paying for a doc out of your own pocket, and paying for extra time. I know this is extremely difficult for most of us, but this is a very good investment. A bad doc who doesn't listen and keeps screwing up at best keeps your life on hold for years and years. And if you're on public assistance or a health plan the bad docs are just about all that are available to you.

Really, we simply cannot afford a bad doc.

If you are on disability or otherwise can't afford a good doc or to pick and choose, I strongly advise pitching your family for funding. In the overall scheme of things, this is a smaller investment than alcohol or cigarettes or fast food, and the benefits are obvious. Your family wants to see you back to full-function as badly as you do, so - trust me - they will listen to your request.

This would make a good topic for a future blog. Feedback, anyone?

Bipolar Test said...

@ Moira

Hi, Can I just say what a relief to find someone who actually knows what theyre talking about on the internet. You definitely know how to bring an issue to light and make it important.

Bipolar Test

Joanne said...

As to "I would strongly suggest paying for a doc out of your own pocket, and paying for extra time. I know this is extremely difficult for most of us, but this is a very good investment." -- Amen! I have paid for my psydoc out of pocket for years. My other docs (internist, gyn, and gastroenterologist) practically worship her. Now that I'm off drugs (she agreed after years of bad reactions to many and little or no effectiveness with any) I rarely see her, but the savings on useless treatment, quality of life, etc., have made the expense more than worthwhile. My previous THREE psychiatrists took insurance, but ALL missed the bipolar diagnosis and prescribed antidepressents (without mood stabilizers) as a result I've got treatment resistant bipolar that has 100% disabled me, rather than the high-paying career I had. They were no bargain.

John McManamy said...

Hey, Joanne. I'm so glad people get to hear this from someone other than myself. :)