OCD - Why Science Has Rendered Antipsychiatry Irrelevant

Antipsychiatry dogma contends that because science has failed to show any link between underlying brain dysfunction and psychiatric symptoms that mental illness is a myth and psychiatry is a fraud.

Antipsychiatrists have been getting away with this for years. Mental illness, after all, is highly complex, which doesn't lend itself to gift-wrapped causes and effects the way a simpler brain illness - say Huntington's - does.

Wait - I take that back. Last night, at my local NAMI here in San Diego, I heard Neal Swerdlow MD, PhD of UCSD talk about obsessive-compulsive disorder (OCD).

OCD is a failure in the brain to screen out certain thoughts. People with OCD, for instance, may drive themselves (and others) crazy obsessing over whether one's pet poodle has succeeded in picking three sets of door locks and is now being carved up for lab experiments.

The thought is ridiculous, but the consequence is deadly serious. Literally, the victim cannot stop the thought. The thought takes over to the point where the victim may feel compelled to leave work and drive home. Should that happen enough times, the victim becomes both unemployable and a social leper.

Dr Swerdlow opened with a short clip of a Huntington's patient. Individuals with Huntington's experience uncontrollable movement. The brain, literally, fails to screen out certain movement impulses. The area of the brain responsible, the cingulate, is the same area of the brain most implicated in OCD.

With Huntington's, of course, the symptoms are obvious (uncontrollable movements). Of course something mechanical in the brain has to be wrong. Uncontrollable thoughts and inner torment, on the other hand, are invisible. Of course psychiatry is at fault for creating a mythical illness out of thin air in order that Big Pharma can sell more drugs.

Forget about the victim.

The problem with OCD, Dr Swerdlow explained, lies in "gating." I have discussed gating on this blog numerous times in relation to schizophrenia. The victim is overwhelmed - too much sensory input, too much thought, too much emotion. The brain can't filter out the irrelevant stuff, cannot focus, cannot function, cannot cope.

In a normal brain, on a cellular level, the neuron essentially makes a "yes-no"decision in response to a neurotransmitter message from another neuron. Air conditioner noise? "No." Not relevant. Tune it out. Instructions from your doctor? "Yes." Very relevant. Pay attention.

On a systems level, the thinking and reacting areas of the brain - and areas in between - are organized around processing and prioritizing all the "incoming." These circuits are referred to as "cortico-striatal-thalamic-cortical loops" and similar-sounding names. Self-correcting feedback is both top-down and bottom up and exists in interdependent relationships with parallel loops.

Neurons that specialize in gating tend to exist in the mid-brain regions, such as the cingulate. In a famous set of experiments performed two decades or so ago, OCD subjects (ones obsessed with cleanliness) shared a brain scan machine with a "dirty" sweat sock. Their respective brain loops lit up like a Christmas tree (much like the image on the right). When exposed to a "clean" sock, their brains quieted down (much like the image on the left).

We know that with Huntington's the neurons in the cingulate die off. There is no gating function to regulate excess dopamine signaling related to movement, and the brain fails to compensate by recruiting gating neurons from other areas of the brain.

Similarly, with OCD, we know that the cingulate is operating below capacity, with about 15 percent less neurons. In some cases, serotonin antidepressants may enhance cingulate function. Or the brain may be successful in recruiting gating neurons from other areas of the brain. This is why CBT and other talking therapies can work so well for OCD and other mental illnesses - often, we can literally train our brains to lay down new roadwork.

Because of our knowledge of cause and effect and our ability to pinpoint an exact location, brain surgery to treat OCD is not only feasible, it is being performed, albeit very rarely and only as a last resort for severe cases on treatment-refractory individuals. Capsulotomies and cingulotomies essentially compensate for lack of gating by surgically turning off the flow of certain brain circuits.

In February this year, the FDA approved deep brain stimulation (DBS) for OCD. DBS has a history of use in Parkinson's and is showing promise for depression. A lead is inserted near the affected brain area. Electrical pulses travel up wiring from a pacemaker device implanted below the brain. For OCD, the signaling from the lead has the effect of interrupting the thoughts that the cingulate is supposed to be screening out.

Brain surgery for psychiatric illness, of course, raises a whole host of ethical and other issues, and you can expect antipsychiatry to add its unmodulated voice to this conversation. But in the context of this blog piece, think of surgery for OCD as the icing on the cake.

Mental illness is indeed, unequivocally real. We can point to the brain systems. We can link breakdowns in these systems to behavior. We have treatments based on this knowledge.

In the face of such overwhelming evidence, why would antipsychiatry think otherwise? Hmm ... defective thought gating?

Figuring Out Schizophrenia - Part III

Yesterday was the last day of the International Congress on Schizophrenia Research, held in San Diego. A brief recap of my third day there:

Early morning: My brain has clearly not booted up, not even after two coffees. I sleepwalk into the main hall for a lecture on "The Hidden Life of Genes: Endophenotyping Schizophrenia," by David Braff of UCSD, the year's recipient of the Congress' prestigious William Warren Award (that's Dr Braff pictured).

I've already given you a major hint into endophenotype: Me, with bipolar, with major difficulty regulating my sleep, which seriously interferes with my ability to function. The general population also experiences sleep disorders, but clearly sleep is tied into my illness.

Thus, rather than look for illness-specific genetic needles in haystacks, it may be more constructive to seek out more common and obvious bio-markers (such as sleep) and work one's way upstream or downstream from there.

Dr Braff was writing about endophenotypes back in the seventies, but it is only within the last five years or so that the topic has really taken off. For instance, Dr Braff explains, patients with schizophrenia experience major problems in sensory gating, ie screening out irrelevant stimuli (such as a noisy ventilation system) which plays havoc with their ability to focus on relevant stimuli (such as a conversation).

What we are finding, according to Dr Braff, is a clustering of patients around various different endophenotypes (eye movement - saccades - involving reaction time is another). Thus, one drug is not going to fit all. The next generation of meds, he says, need to be far more specific.

Schizophrenia, Dr Braff concluds, is a malignant terrible disease that is not going to give up its secrets readily. Instead, we "have to conquer schizophrenia gene by gene, step by step."

Late morning: "Optimizing Cognitive Training Approaches in Schizphrenia," reads the title to this two-hour symposium. Translation: The brain is plastic. As Michael Merzenich of UCLA describes it, "Basically, we create ourselves."

The brain is born stupid, then evolves and becomes "massively optimized to fit into your world."

In recognition of this, a relatively new field is opening up that involves drilling patients in cognitive tasks we tend to take for granted, such as holding a thought in our working memory long enough to lay down new neural roadwork or responding to stimuli in a timely fashion.

New computer programs are being developed and being tested on patients, Sophia Vinogradov of UCSF explains, and we are seeing enduring changes in the cognitive performance of patients six months later.

Afternoon: Today's poster presentation has a treatment theme, and here there is a clear disconnect from the rest of the conference and earlier poster presentations. Pharma is out in force, with products based on 50s technology. An example:

I stop at a J&J poster testing Invega on a schizo-affective population. No surprise, the antipsychotic knocks out the psychosis. Invega is son of Risperdal, which in turn is a descendant of Haldol.

See what I'm driving at? The emphasis of current schizophrenia research is on cognition and the underlying biology. Psychosis is what gets patients in trouble, but difficulties thinking is what keeps them from winning back their lives. Pharma has nothing in its current inventory for this, but they're still in a state of denial pretending that they are still relevant. (Think Detroit, only not nearly as smart.)

So here is J&J, pitching a med with roots in the 1950s, with a study designed for no other purpose than to milk its current patent. I ask some of the other researchers about this and get a lot of nodding heads and knowing looks.

If only these researchers were running Pharma, I can only think. The good news: Everywhere, Pharma is clearly losing both its influence and credibility. The bad news: In another year or two, we are going to know J&J as makers of baby powder and other fine consumer products. Same with the other drug companies.

Where, then, are the new smart meds going to come from?

Much more in future blog posts ...

April Fools

See if you can distinguish the real stories from the fake pieces below. Warning: If truth is stranger than fiction, then fiction can be more credible than truth - and often more true. Ah! the hazards of being crazy in a crazy world. But we're the ones being treated.

Also, my good friend Therese Borchard at Beyond Blue has compiled a great April Fools collection. Please, check it out.

Laugh - it's good for you. Believe me, without laughter I'd be dead.

Enjoy ...

Darwin Award to Leading Antipsychiatrist

The Darwin Awards Committee has announced that its top prize for 2009 goes to prominent antipsychiatry spokesperson, Clovis Bullright.

The Darwin Awards honor people who "do a service to Humanity by removing themselves from the gene pool."

The 55-year-old Mr Bullright has specialized in taking himself out of the gene pool his entire adult life through behavior seemingly designed to repel the opposite sex. A new psychiatric diagnosis in his honor is scheduled to appear in the next edition of the DSM in 2012.

Nevertheless, Mr Bullright refuses to acknowledge anything out of the ordinary about his Guinness World Record list of symptoms, much less take medications or enter therapy. "People who value individuality," he once wrote from jail, "don't complain when you leave a turd on the table."

Mr Bullright found his niche in the antipsychiatry movement, where thinking is not a requirement. Over the years, he has built up a following of people who subscribe to his beliefs that Big Pharma is responsible for the future assassination of JFK.

"It's simple," he explained. "Lee Harvey Oswald spelled backwards is Zyprexa."

His book, "You Can All Gargle Razor Blades," is regarded as an antipsychiatry classic.

Unfortunately for Mr Bullright - but fortunately for the genetic future of humankind - his success as an antipsychiatrist does not translate well in the real world. "What part of 'nice boob job' don't women understand?" he once said from the back of a police car.

Nevertheless, the year started out on a promising note when Mr Bullright entered an email relationship with a woman also not on meds. "You would almost look passable if you stuck your face in a wind turbine," he is reported as saying by way of introduction.

His correspondent interpreted this as a declaration of love, and in no time the two agreed to meet up in a secluded section of the local park.

At the appointed hour, the woman rode up on a bicycle, jumped off, removed her clothes, and invited him to "take anything you want."

Mr Bullright took the bicycle and rode off, thereby permanently removing himself from the gene pool.

Landmark National Gorilla Suit Day Study Yields Breakthrough Insights into Human Behavior

A Knowledge is Necessity Exclusive

The research community is abuzz with reports of a series of studies that are scheduled to appear in Nature, the journal that published Watson and Crick's landmark DNA findings in 1953. Scientists are unanimous in their view that the current findings are equally significant.

Says Dunstar Fobash MD, PhD, Director of the Kuhn Institute of Advanced Paradigms affiliated with MIT and Princeton: "These discoveries will change the way we think about everything, literally - everything."

Researchers from the National University of Mongolia surveyed a large population of people who wore gorilla suits to work on National Gorilla Suit Day, then tracked their progress over ten years. Each year, the subjects and their families were administered a battery of innovative medical and psychological exams that included sophisticated genetic testing and brain scans in the University's state-of-the-art facilities.

National Gorilla Suit Day is the 1964 brainchild of the late Mad Magazine cartoonist Don Martin, and is celebrated worldwide every Jan 31. In Mongolia, National Gorilla Suit Day is a national institution, equating to Halloween. In Ulan Bator, the capital, virtually the entire population turns out to work in gorilla suits.

Because Ulan Bator has the lowest average temperature of any capital city in the world, many residents wear their gorilla suits year round, thus affording scientists a rare and unprecedented research opportunity. According to experts, the "Ulan Bator Gorilla Suit Cohort" represents by far the largest and most comprehensive human study population in the world.

"The potential for mind-boggling discoveries to come from this study is literally mind-boggling," says Dyson Freeman, the 2003 recipient of the Nobel Prize in Sociology and Mathematics.

Some of the early findings from the study include:

• Nerds and geeks can get laid any time they want. It's just that they don't want to get laid.
• A nerd is an individual not smart enough to be a geek.
• The discovery of the previously thought to be inconceivable "Theta Male." Think Henry Kissinger meets Janet Reno.
• The identity of a mysterious region in the male brain comprising just two neurons. When it comes to all matters related to sex, these two neurons override the 100 billion other neurons in the brain.
• Females have a similar two-neuron region in the brain thought to be related to shopping.
• The discovery of a "biological hour glass," located in the same region of the brain as the "biological clock." According to preliminary findings, the human race is programmed to become extinct in the next three to three hundred years, which ever comes first.
• The possibility of a "biological hand" in the brain to turn over the biological hour glass. Other scientists believe that the "biological hand" may have more to do with a yet-to-be-discovered new source of male orgasm.

Researchers acknowledge one major weakness in the study. In 2004, the Mongolian government declared National Gorilla Suit Day an official holiday, which meant all places of work closed down for the day. In 2005, the government realized this defeated the purpose of the holiday, which is all about wearing gorilla suits to work.

"Talk about all dressed up and nowhere to go," remarked Jugderdemidiyn Gurragcha PhD, who headed up the study. "But pissed off people in gorilla suits make an interesting study in themselves. Especially the Theta males."

The first of the studies from the Ulan Bator Gorilla Suit Cohort is scheduled to appear in Nature on April 25, exactly 56 years from the date of the historic publication of Watson and Crick's, "Molecular Structure of Deoxypentose Nucleic Acids."

Figuring Out Schizophrenia - Part II

Another full day at the International Congress on Schizophrenia Research, here in San Diego. To recap:

Breakfast: Beatriz Luna of the University of Pittsburgh tells me she isn't a schizophrenia researcher. Rather, she's into something called "development." I'm thinking development, as in a child psychologist.

No, she tells me. This is about brain development, as in the child brain maturing into the adult brain. She will be one of the speakers at a two-hour symposium later in the morning. (That's her in the photo.) Curious, I check it out:

Think of research into normal brain development shedding valuable light on schizophrenia, and, by extension, all of mental illness. The first speaker, Patricio O'Donnell of the University of Maryland, talks about cortical microcircuits and the balance between excitation and inhibition. Dopamine, he says, plays a large role in the modulation of circuits in the prefrontal cortex. During adolescence, he explains, these circuits experience dramatic connecting changes.

For instance, "phasic dopamine" (firing in bursts) gets dialed in, with improved signal to noise ratios.

But suppose the brain doesn't mature? Are we then looking at an approximation of schizophrenia?

David Lewis of the University of Pittsburgh shows slides that highlight the neuron's "dendritic spines." These spines play a major role in brain cells talking to one another. We know that people with schizophrenia are not favorably endowed in this category, but what does it mean?

In normal brain development, he explains, there is an early dramatic increase in spine density followed by a dropping off in adolescence and leveling out in adulthood. But are we talking about a drop-off in "functionally mature" or "functionally immature" connections? In other words, when the brain experiences structural changes, are the right chemical messages crossing the dendritic divide or the wrong ones?

Early intervention, he says, might be directed at enhancing the normal development of these synapses.

Dr Luna informs the audience that adolescence involves major risk of mental illness. As she explained to me over breakfast, this is when the brain changes gears. But what if something goes wrong in the transition? Might this underlie the pathology of mental illness?

During adolescence, the brain undergoes "synaptic pruning," along with axonal "myelination." In essence, brain function becomes more equally distributed, with less reliance on impulses from the basal ganglia and other more primitive regions of the brain.

But what if something goes wrong? Normal child brain function is suddenly not so normal, not in an adult brain anyway. You can kind of see this with the current economic meltdown, Dr Luna explains. It's a new world. AIG and GM and the rest can't behave the way they used to. The failure in executive behavior in this new context, she concludes, now becomes obvious.

Lunch time posters: This is where I get to ask all my stupid questions. For instance, over the past two days, the area of the brain I've been hearing most about is the dorsolateral prefrontal cortex, the brain function I've been hearing the most about is working memory, and the researcher I have been hearing most about is Joseph Callicot of the NIMH.

"Allelic Variation in KCNH2 is Associated with Dorsolateral Prefrontal Cortex Activation During Working Memory," reads the poster.

The name tag on the man standing in front of the poster reads Joseph Callicot.

Knock me over with a feather. Fire away with all your stupid questions, says the look on his face.

I love this job ...

Figuring Out Schizophrenia

I'm back home after an exhilarating and exhausting day at the International Congress on Schizophrenia Research in San Diego, 40 miles "down the hill" from where I live. To briefly recap:

Early morning: I'm up at 5 AM and out the door an hour later. Shortly after seven, I announce myself to a small breakfast gathering of brain researchers as, "The only C student at this table."

The line works so well I use it the rest of the day. It doesn't take me long to get into the spirit of the conference. I start referring to my coffee as my "neuro-cognitive starter." I find myself talking to a woman who is not a brain scientist. Her doctorate is in education, and she is involved in changing behavior in patients that just about everyone else has given up on.

"You can change the brain by changing behavior," she lets me know. Little steps at a time. You will probably hearing a lot more about her, if for no other reason than I plan to be writing more about her.

Late morning: I arrive at my appointed symposium for two hours of dopamine. These are brain scientists talking to brain scientists. To give you some perspective: When brain scientists talk to psychiatrists, they dumb down their talks. That way, I can almost understand their presentations.

Not the case here. Daniel Weinberger of the NIMH is one of the presenters. A couple of years ago, at the American Psychiatric Association annual meeting, I heard him explain to his audience the val-met COMT variation. Today, he just assumes that the people in the audience understood. Then he gets really technical.

Just over the aisle, in the same row where I am sitting is Arvid Carlsson, recipient of the 2000 Nobel Prize in Medicine (with Paul Greengard and Eric Kandel). Dr Carlsson received his Nobel for his work into dopamine. Let's put it this way: BC (Before Carlsson), dopamine had minor chemical status. Then Dr Carlsson started investigating and suddenly dopamine was a major neurotransmitter. (That's Dr Carlsson's photo to this blog post.)

In order to appreciate the environment Dr Carlsson was working in at the time, science only had theories about how brain cells communicated. Chemical? Electrical? Dr Carlsson and his contemporaries resolved that debate, but not without bucking a lot of the conventional wisdom of the day. In addition, Dr Carlsson connected dopamine deficiency to Parkinson's, which in turn led to L-DOPA for treating the illness, thus benefiting untold millions.

So here's Dr Carlsson listening to a younger generation of scientists carry on his work. Immediately after the session, I walk over and ask for his autograph. (I was a C student, remember? I can get away with this behavior.) He graciously signs the inside back cover of my conference booklet. My son-in-law is a neurosurgeon in New Zealand and a great guy. He's gonna be thrilled when this autograph arrives in the mail.

Don't tell - it's a surprise.

Early afternoon: Over lunch and at the poster session, I get to talk to the researchers one on one. First, let me make a confession - the technical stuff is way over my head. I'm here to simply get a feel for things, develop an appreciation. One of the things I notice is that the posters on the cognitive aspects of schizophrenia outnumber the psychosis side of the illness by a ratio of at least three to one.

Was it this way ten years ago? I wonder. I'll have to ask. Antipsychotics work very well against psychosis, but when your basic thinking is messed up - never mind the psychosis - your life is going to involve smoking cigarettes in front of TV in some dreary day room someplace.

No wonder the people I'm talking to are telling me that doctors and patients and family members got oversold on the new generation of antipsychotics. From what I can gather, certain systems in the brain go down. Systems we are only just finding out about. Systems we haven't even discovered yet. Systems all over the brain, interdependent, so when one system goes down, different parts of the brain all over fail to talk to one another.

Some of it is genetic. Some of the genetic mischief occurs during fetal development, other mischief further on in the life span. There may be direct genetic impact, or it may be like billiard balls caroming off one another. Or it may have something to do with a new area of gene research called epigenetics (which has something to do with why identical twins aren't really identical).

And forget about finding schizophrenia genes. These guys seem to be concentrating on "endophenotypes," symptoms common to the general population, as well, say, delayed reaction time to an event. If, say, we find a delayed reaction time gene and connect it to neurons and connect the neurons to brain systems and connect the brain systems to behavior, and connect the behavior to schizophrenia, maybe then we can really start connecting some dots.

Then there's environmental factors. The brain is shaped by literally everything, such as the way a mother holds her baby. African-Caribbean immigrants in the UK, for instance, have a nine-fold higher schizophrenia risk than the rest of the population there. What is going on?

Later afternoon: My brain is on overload. I leave the conference at four and am home at five. Twenty minutes later, I'm crashing in my own bed.

Evening: Dinner, chill time, and this blog post. Time to kick the cat off the prime spot on my bed. Up at five again tomorrow. I love my job ...

Reporting on Schizophrenia Research

My annual conference season unexpectedly began three weeks early today, when I attended what I thought would be an afternoon local family forum on schizophrenia. I turned up at the Grand Hyatt on San Diego's waterfront only discover the forum was a satellite to a four-day major world conference: The International Conference on Schizophrenia Research, held every two years.

So that explained the star-studded list of speakers at our local family forum.

(Small sound-bite from that forum: According to John McGrath MD, PhD of the University of Queensland, hallucinations and delusions are "very very common" in the general population. Four percent of the US population hears voices.)

As soon as the forum ended, I headed over to the registration area of the main conference to secure media credentials. Mind you, here I was, a mental health journalist feeling obliged to explain why I knew nothing about a major world schizophrenia conference in my own backyard until today.

"Bipolar," I said to someone behind the desk, pointing to a copy of my book I happened to have in my bag, as if that explained everything. Another person was called over to assist.

"Tamminga," said the name on her tag.

She caught the look on my face. "It looks like you're familiar with the name," she said. "I'm her daughter." As in daughter of Carol Tamminga MD of the University of Texas Southwestern Medical Center, first rank researcher and one of the conference organizers. In addition, Dr Tamminga is very generous in giving her time to NAMI and other causes. (That's Dr Tamminga's photo on this blog post.)

Nearly two years ago I happened to sit next to Dr Tamminga over dinner in Pittsburgh at a closed function at the Seventh International Conference on Bipolar Disorder. (I was a special guest by virtue of a public service award I would receive two nights later.) Just to show you what a thoroughly gracious person Dr Tamminga is, our section of the table also included Thomas Insel MD, head of the NIMH, and Darrel Regier MD, co-chair of the DSM-V task force, but Dr Tamminga talked to me as if the other two weren't there.

"I was about to use your mother as a reference," I joked, then I briefly explained the connection.

Ten minutes later, I was at a patio table, poring over my conference materials. A brain scientist from Australia sat down, and for the next hour we talked about the brain, the metric system, politics, the environment, Einstein, and autism (she has a son with autism). Ninety percent of marriages involving an autistic child end in divorce, she informed me.

Tomorrow, I will be waking up before dawn to catch Dr Insel at a plenary session, then over to a morning symposium on "Dopamine Signaling in the Era of Molecular and Genetic Pathways." I'll hit the research poster sessions over lunch, then take in an afternoon of "Aberrant Functional Connectivity in Schizophrenia: Changes in Frequency, Symptoms, Drugs, and Genes."

Tuesday and Wednesday will be more of the same.

What is a depression and bipolar writer doing at a schizophrenia conference? From a recent blog post:

Back in 2003, I had one of those breakthrough moments, the type you associate with light bulbs switching on. I was at the American Psychiatric Association's annual meeting attending a symposium on genetics. Robert Freedman MD of the University of Colorado started explaining his research into schizophrenia.

"The DSM-IV was not designed with human gene function in mind and genes do not encode for psychopathology," he said. Instead, "genes encode simple molecules in cells that alter cell function and brain information processing."

I had kind of been aware of this, but this time I went, "Aha!" ... The upshot of my Aha! moment was the realization that to better understand my own illness (bipolar) I needed to research other illnesses as well, such as schizophrenia. The brain, after all, doesn't organize itself according to the DSM.

Listening to the schizophrenia people, in effect, gives me insights into my illness that I would never get from limiting my enquiry to the mood disorders experts. Take my word for it, I'm like a kid in a candy store at these events. The only thing about my job that I love more than listening to super-smart people who have dedicated their lives to improving yours and mine is writing about it.

Stay tuned ...

What's Wrong with Pharma? They Don't Listen to Their Customers

In my last blog piece, I presented a simplified overview of the appalling Pharma management practices that have resulted in no truly new psychiatric meds on the market in more than 50 years, with no replacement drugs on tap that they can even pretend to call new.

What went wrong? Lots of things. But it all boils down to this one cardinal sin: Pharma never listened to its customers.

My background as a finance/business journalist has given me considerable insight into this. Back in the late eighties, when I lived in Australia, I co-wrote a book with a prominent businessperson there, entitled "The Customer," which went to number two on the best-seller list.

It's all about organizing your business around the customer. If management isn't directly serving the customer, then they need to be serving the people serving the customer. It's amazing how entire industries get this principle wrong. Detroit, for instance, has always dictated the terms of the customer relationship. Marketing, to them, is about conditioning us into acceptance rather than finding out what we want.

Look at where Detroit is now.

Detroit, at least, pretends to listen to the customer. Pharma? Let me tell you a story:

Two years ago, I was at a book launch on the east coast. I grabbed some finger food and started up a conversation with a pharmacology expert from Bristol-Myers Squibb.

"Maybe you can enlighten me," I opened. I had been doing some research into dopamine and had pretty well concluded that stimulants and antipsychotics amounted to "dumb" dopamine meds.

We needed "smart" dopamine meds. Surely, Bristol-Myers Squibb was aware of the situation. Surely, such a drug was at least on their radar screens, if not their drawing boards.

(For background on the issue, please see For Discussion: Dopamine Cocktail.)

We actually have a smart dopamine med, the man informed me. "Aripiprozole."

Surely, he misunderstood. Nothing against Aripiprozole (Abilify), but it's been on the market for years. I was looking into the future. I realized he wasn't in a position to disclose any company trade secrets, but he could at least fill me in on some general principles, namely: Where were the next new meds going to come from?

I'm a customer. I have a right to ask.

It was if the man hadn't heard me. Once again, he started talking about aripiprozole, undoubtedly the exact same pitch he gives to psychiatrists. For years, BMS has been telling doctors that aripiprozole is a "Goldilocks" drug - not too much dopamine, not too little, just right.

Stop trying to sell me something. I'm a journalist. I've heard it all before.

Again, I tried to get the conversation back on track. Again, the man tied to shove his stupid drug down my throat. It never occurred to him to ask me why I was so interested in a "smart" dopamine med in the first place.

Were there special challenges I faced that a smart dopamine med might address? he could have asked.

Was there anything about my illness that he needed to know, that he wasn't finding out about from psychiatrists? If a "magic bullet" were to come on the market tomorrow, how would this affect my life? What impact would a safer and more effective med have on my compliance?

Believe it or not, this man could have learned a lot from me. So could BMS and their competitors. Let me assure you, no one in the entire drug industry has even bothered to ask. I'm a patient author and advocate, so if they're not interested in me then I know they are not interested in you, either.

Actually, BMS did bring a patient author on board, Andy Behrman, author of "Electroboy," but in the capacity as a spokesperson - a grateful patient - for Abilify. The arrangement worked fine until the drug pooped out and Andy went public. Then all hell broke loose. (Never piss off a writer: Andy has a tell-all book coming out.)

So what happens to companies not interested in listening to their customers? We know the answer. The evidence is there. Detroit, Wall Street, Pharma ...

"How deserted lies the city," says Lamentations, "once so full of people!"

It's tempting to say, "good riddance," but if Pharma goes down, what becomes of us?

Big Pharma: Dumber Than Detroit

More than a year ago, I wrote that Big Pharma may go the way of Detroit. Detroit, I wrote, won't be around 10 years from now. Little did I realize how prescient I was.

An opinion piece in the LA Times by author Greg Critser neatly encapsulates things the patient community has been discussing over the past 10 years:

First of all, Mr Critser notes, the meds don't work well. (Assuming the drug is reasonably safe, 50 percent of patients getting 50 percent better is all that is required for an FDA indication.) Nevertheless, even badly flawed meds have amounted to licenses to print money. Think Prozac. Think Zyprexa.

But these drugs have now ridden off into the sunset - gone generic - and there is nothing to replace them.

No new drugs. How stupid is this? Imagine if the movie industry were to announce that there were no new films in production, that holiday movie-goers were going to have to make do with the likes of "Parent Trap I."

According to the LA Times piece:

"As Bloomberg News Service recently reported, the world's pharmaceutical firms need to find replacements for $84 billion in sales now generated by products ending their patent life."

Sounds like appallingly bad management, right? No, it's always someone else's fault:

"If you ask the typical Pharma executive why sales are down, you get an alternative reality. The devil isn't in their drugs, it's in - surprise - onerous government regulation, penny-pinching insurers and, of course, that perennial boogeyman: healthcare reform."

Here's my very simplified take on what happened: In the eighties and nineties, Big Pharma got lucky with a new generation of antidepressants and antipsychotics. The drugs were hardly new - they were based on the same technology as the old ones - but they were promoted as new.

Psychiatry and patients' groups bought into the hype and the result was easy money.

As any business textbook will teach you, easy money is the greatest disincentive to sound management. Bad decisions and waste do not get penalized. Innovation and efficiency do not get rewarded. Necessary course corrections are not made.

During the easy times, the drug companies got out of the drug development business. Research went into "me-too" drugs - different versions of Prozac and Zyprexa. Corporate attention was devoted to lobbying the government (Big Pharma has way more lobbyists than any other industry) and wooing doctors (typically with drug reps who look like Heidi Klum and Russell Crowe).

The easy money, of course, ran out, but we're still stuck with the same bad management, ingrained in their easy money bad habits.

So, when, if ever, will we get meds that are a real improvement on the old ones?

Short answer: Never. Not with the current managers in place. Take my word for it - these guys are dumber than Detroit.

Much more to come ...

Further reading from mcmanweb

Blue Moon Musings

I'm not through: I'm strongly getting the impression you guys are like the auto industry. Same old engines, new fins. In case you haven't noticed, Detroit probably won’t be around ten years from now.

You are the only industry that doesn’t talk to its customers, the end users of your products, and it shows. You certainly haven't sent any Heidi Klum look-alikes to my door. ..