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 Salary.com) 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.

John Gartner on Treating Hypomania

On his latest blog piece on Psychology Today - Malpractice Is the Standard of Care When Medicating Hypomanics - John Gartner (pictured here)  cited me twice. Actually, Dr Gartner was my prime influence in my rethinking of hypomania, as this extract from a much longer mcmanweb article - Treating Hypomania, dating from 2005 - attests. I substantially rewrote the article earlier this year, but this extract has stayed intact ...

Said John Gartner PhD, an associate professor of clinical psychiatry at Johns Hopkins and author of "The Hypomanic Edge: The Link Between a Little Craziness and a Lot of Success in America," in a 2005 interview with this writer, "the most common form of this disorder is being treated as if it were a rare weird variation."

In his book Dr Gartner views hypomania as a genetically transmitted temperament whose adaptive advantages far outweighs the disadvantages. Thanks to the people brave enough (and crazy enough) to leave their settled existences to strike out for an uncertain life on a strange shore, argues Dr Gartner, America has been blessed with a generous supply of wild wacky creative geniuses and go-getters, plus an abundance of those egging them on. This is often a source of dismay to the Europeans, who are alarmed by our excesses, even as they embrace the many positive aspects of our culture. (See Hypomanic Nation.)

One of Dr Gartner’s case studies is the brilliant Founding Father Alexander Hamilton, who had a spot reserved on Mt Rushmore until he stupidly offered up his body for target practice. Which raises some interesting questions. Suppose lithium and other meds had been available to Hamilton. Would the treatment have dulled his brain to the point where he would have opted to become a Founding Bystander rather than a Founding Father? Or would he have prudently skipped his appointment with Aaron Burr and gone on to become America’s greatest President?

$64,000 question for psychiatrists: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?

Certainly, many of us feel hypomania is our true identity, not just a mood aberration to be medicated out of existence. "That’s very important," Dr Gartner told me. "When you think about it, how many people have died just to preserve their sense of identity? Think of all the Jews who died because they wouldn't renounce their religion. All they had to say was, yes I’m a Christian. It’s hard for people who are not hypomanic to appreciate how integral this is to someone’s identity and how important it is to preserve that."

This led to the crux of our interview: "First of all, most psychiatrists don’t know when their patients are hypomanic because they haven’t been trained to look for it. Also, no one ever came to their offices saying, I’ve got hypomania, please cure me. When they do become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."

Some people can obviously benefit from meds, but Dr Gartner makes it clear we are talking of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge."

"I liken it to the pitcher in Bull Durham," he related, "the guy who has the 100 mile per hour fastball but keeps beaning the mascot. He needs a little bit more control. He’s got speed. You wouldn’t want to give him so much medicine that he threw a fifty mile per hour fastball. We want to slow it down just enough so that he can deliver the ball where it’s supposed to be."

Think of Hamilton, brilliant as ever, lightening up a tad on Aaron Burr.

This may involve clinicians rethinking their concept of therapeutic doses. Current dosing levels are based on trials involving bipolar I patients in the acute (initial) stage of mania. Even lithium, the most studied mood stabilizer, has not been tested for hypomania. Clinical treatment guidelines are silent on the topic. In this so-called era of evidence-based medicine, we simply have no evidence.

Check out John Gartner's website

Alexander Hamilton, Hypomanic Founding Father

This Fourth of July special is lifted from a much longer article on mcmanweb, a review of John Gartner's "The Hypomanic Edge" ...

"Danger, Hypomanic on Board," could well be the other title of "Washington Crossing the Delaware." With him that historic night was Alexander Hamilton, most famous for being on the losing end of a duel with Aaron Burr. Biographer Ron Chernow describes Hamilton as "a volatile personality," and an "exuberant genius" who was prone to poor judgment and "prey to depression." Dr Gartner surveyed five of Hamilton's biographers without telling them the illness he was investigating. Even though only one biographer had suggested in his book that Hamilton may have had bipolar disorder, all of them overwhelmingly in the survey awarded the Founding Father very high marks for hypomania.

Soon after graduating from Columbia University in two years, Hamilton caught revolutionary fever. In one two-week period he spewed out the equivalent of a book in the form of 60,000 words of propaganda. During a raid, when everyone else had ducked for cover, Hamilton walked straight into an artillery bombardment. He soon caught the attention of George Washington and became his aide de camp, only to impulsively quit a few years later. At Yorktown, now with a battlefield command, he paraded his troops in front of British cannons. The British were too dumbstruck to open fire. Later in the battle, Hamilton led a reckless charge that turned out right for all the wrong reasons.

Hamilton was the main instigator of the Constitutional Convention, but one biographer described him during this period as "restless and depressed," and another "like he was on something." He delivered an impassioned six-hour speech, then walked out for good in disgust, unable to appreciate why the delegates couldn’t simply settle their differences and back his brilliant proposals. Nevertheless, once the document was ready for ratification by the states, Hamilton became its greatest champion, cranking out 51 of the 85 op-ed pieces collectively known as the Federalist Papers. He was also the political point man in winning over New York.

By the time Hamilton assumed his post as first Secretary of the Treasury, the new nation was on the brink of financial collapse. Hamilton’s inspired plan was to consolidate state debts and federal debts into one restructured national debt, paid off in monthly installments. The result was a strong and robust federal government that set the scene for a nation of capitalist go-getters, much to the consternation of Thomas Jefferson who envisioned a pastoral utopia. Fittingly, Hamilton is buried in a graveyard on Wall Street.

See full article: Hypomanic Nation

Craig Venter: Hypomanic

Following is an extract from a lengthy review I first published in my Newsletter in late 2004, and on mcmanweb in 2005 ...

"Up until 2003, only God could claim to have created life. The Almighty must now share that honor with a hypomanic American."

That provocative statement comes from the book, "The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America" by John Gartner PhD.

Dr Gartner is an associate professor of psychiatry at Johns Hopkins. The book invites an obvious comparison to one published in 2004 by his university colleague Kay Jamison PhD, "Exuberance: The Passion for Life". But that book downplayed the bipolar connection, much to the disappointment of many admirers of her previous "Touched with Fire."

Not so with Dr Gartner’s work, which contends that America would not be what it is today without the hypomanic drive of the people who settled, founded, and shaped a nation in their image. Exhibit A is God’s partner in creating life, Craig Venter.

Readers may recall a June 2000 White House ceremony in which President Clinton announced a "tie" between two competing groups to sequence the human genome: the official government effort, the Human Genome Project (HGP) headed up by Francis Collins and a breakaway private venture bankrolled by a new company, Celera, run by maverick geneticist Craig Venter.

In fact, the tie was a political sham engineered by the White House with the collusion of both parties. Celera had actually run rings around the opposition, smoked them, waxed them, wiped the floor with their face. It wasn’t even close. Not only had Celera crossed the finish line well ahead of the HGP, it delivered a more complete genetic blueprint. To add insult to injury, the only way the HGP could even stay in the race was by scrapping its own plodding methods and game plan for Celera’s.

Craig Venter was a wild man from day one. As a kid, he liked to race his bike on the local airport runway as planes took off. In the Army, he frequently got on the wrong side of his superiors. On acceptance to a university faculty position, he wasted no time turning colleagues into enemies, then evinced surprise when they refused to grant him tenure. He arrived at the NIH and caught the attention of his hero, James Watson, but became disillusioned when the great man tactlessly treated him as a mere technician and publicly humiliated him in a Senate hearing.

Venter acknowledged to Dr Gartner that he probably has "a very mild case of manic depression." When the author described bipolar II to him, he replied, "That characterizes some pretty big stretches of my life."

Driven into the private sector, Venter in 1995 revolutionized microbiology by successfully mapping the H flu genome using a novel "shotgun" method. At the time, the HGP was in full swing. Three years later, with the support of Celera, Venter made the surprise announcement that he would map the human genome four years ahead of the HGP’s target date at one tenth the cost. As Dr Gartner describes it: "What psychiatrists call ‘impulsivity,’ entrepreneurs call ‘seizing the moment.’"

Venter added that Collins’ team should just quit now and stick to mapping the mouse.

A few days later he turned up uninvited at a HGP meeting and taunted the participants. One scientist wanted to slug him and another strangle him. But the affront energized the opposition and instilled in them a newfound sense of urgency. Meanwhile, Venter mobilized his troops with the charismatic élan of a battlefield commander. A colleague compared his efforts to high dives into empty pools, timed so that the water would be there by the time he hit bottom.

In the end, Venter nailed all his landings, a full five years ahead of HGP’s original schedule. Under the terms of the White House agreement, neither party was supposed to attack the other’s work, but embittered HGP scientists simply couldn’t help themselves. Even Mother Teresa would hate the guy.

Venter proved equally successful in alienating his financial backers. In 2002, Celera fired him and he went into a depression, only to bounce back as head of the privately-funded "Genesis Project," which effectively created life by building a virus from scratch. A team at the State University of New York at Stony Book had accomplished a similar feat shortly before, but their effort had taken three years compared to Venter’s 14 days.

Now science was truly playing God, for better or for worse, with the potential to transform the world or destroy it. It’s the kind of challenge that hypomanics live for.

See the full review on mcmanweb

Columbus, religious dissidents, Alexander Hamilton, Andrew Carnegie, the Hollywood moguls ...