DOES AMERICAN PSYCHIATRY MATTER?

<br />DOES AMERICAN PSYCHIATRY MATTER?<br /><br />The blogmeister of 1boringoldman.com has done it again. A semi-retired psychiatrist in rural Georgia, he has done more than anyone to document the follies and the ethical challenges of contemporary American psychiatry. His site is required reading for all who care about behavioral health issues. <br /><br />In his <a href="http://1boringoldman.com/index.php/2012/11/02/cest-la-vie/">latest posting</a> he compared the domain of American psychiatry to Yugoslavia. Cast Melvin Sabshin as Marshal Tito. Sabshin was the medical director of the American Psychiatric Association in the late 1970s, the period leading up to DSM-III. Tito and Sabshin each strong-armed a confederation of sorts but failed to deal with the conflicts beneath the surface. Both leaders were faced with the prospect of their domains disintegrating – Tito’s at the hands of Moscow and Sabshin’s at the hands of insurance companies. Both persuaded wary stakeholders to sign on to a compromise, for want of anything better and fearing a worse outcome.<br /><br />The domain of psychiatry hasn’t yet reached the stage of ethnic cleansing and genocide that we saw in Yugoslavia after Tito’s death, but it is well on the way. One only has to look at the vicious response of the American Psychiatric Association leaders to Allen Frances and other critics of DSM-5. The APA president in 2009, Alan Schatzberg from Stanford, went out of his way to <a href="http://www.psychi%20imes.com/dsm-5/content/article/10168/1425806atrict">smear</a> Dr. Frances and Robert Spitzer, the architects of DSM-IV and DSM-III because he had no credible scientific response to their criticisms of the directions DSM-5 is taking. He was joined in this low act by David Kupfer and Darrel Regier, who are directing the DSM-5 effort. Where is the comity, Comrades? Where are the shared values? Why is the APA holed up in a bunker?<br /><br />Then we have the unsavory sight of the APA lawyers <a href="http://hcrenewal.blogspot.com/2012/01/self-inflicted-damage.html">threatening</a> a blogfrauchen in the U.K. with a SLAPP lawsuit for alleged infringement on the APA’s intellectual property – as though the APA owns psychiatric classification! Talk about chutzpah. So now the confederation Sabshin cobbled together is breaking up and the stakeholders are starting to go their separate ways – psychologists, counselors, social workers, patient advocacy groups, even many psychiatrists. Christopher Lane in <a href="http://www.psychologytoday.com/blog/side-effects/200912/american-psychiatry-is-facing-civil-war-over-its-diagnostic-manual">Psychology Today</a> has said American psychiatry is facing “Civil War” over its diagnostic manual. Even an international psychiatric journal like British Journal of Psychiatry is <a href="http://bjp.rcpsych.org/content/201/4/334.full">distancing itself</a> from DSM-5 and there is talk of abandoning DSM-5 for the next ICD classification.<br /><br />Why is American psychiatry self destructing? Because the grand bargain forged in 1980 with DSM-III was a sham from the get-go and the promised benefits of diagnostic reliability have not materialized. They knew all along that reliability was a poor substitute for validity, but they settled for half a loaf. That compromise led us into the <a href="http://hcrenewal.blogspot.com/2009/04/in-defense-of-psychiatric-diagnoses-and.html">epistemologic quagmire</a> of today, where there is no solid ground for clinical decisions or clinical research progress or drug development. A stunning absence from the DSMs to date is any statement about treatment. That compromise also led us to diagnostic inflation, which Pharma embraced. Pharma quickly filled the vacuum with <a href="http://www.ncbi.nlm.nih.gov/pubmed/15169734">experimercials</a> that <a href="http://hcrenewal.blogspot.com/2012/10/when-clinical-trials-are-meant-for.html">pretended</a> to be real clinical science, and in the process diverted precious clinical research infrastructure away from genuinely important questions. Just look at the clinical trials er, experimercials, mill operating out of Massachusetts General Hospital at Harvard University.<br /><br />What lies ahead? Stakeholders are going to vote with their feet. DSM-5 is likely to be a footnote in the history of psychiatric classification. The APA will become even less relevant than it is today, much like the American Medical Association, which now commands the loyalty of maybe <a href="http://mediamatters.org/research/2009/06/15/nbcs-guthrie-falsely-suggests-ama-represents-th/151182">30% of U.S. physicians</a>. Mel Sabshin will turn in his grave, the APA will lose revenue, ICD-11 will become the dominant classification of psychiatric disorders, and the quagmire will continue until a new synthesis arises from the ashes. If Yugoslavia is any kind of model, don’t hold your breath.<br /><br />

DOES AMERICAN PSYCHIATRY MATTER?

DOES AMERICAN PSYCHIATRY MATTER?The blogmeister of 1boringoldman.com has done it again. A semi-retired psychiatrist in rural Georgia, he has done more than anyone to document the follies and the ethic…

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SELF INFLICTED DAMAGE

SELF INFLICTED DAMAGE <br /><br />The American Psychiatric Association (APA) is in the news again for bad public relations: worse than bad, actually – appalling. Locked in a bunker mentality, they have moved to stifle advance criticism of their flagship initiative, DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), which is a work in progress. Lawyers for the APA have threatened the owner of a UK blog that served as a discussion forum for issues affected by DSM-5 and other, international psychiatric classifications. The blog, named <a href="http://dsm5watch.wordpress.com/">dsm5watch</a> was considered authoritative and accurate. If you go to this site now you will find that it has been deleted.<br /><br />As <a href="http://www.psychologytoday.com/blog/dsm5-in-distress/201201/is-dsm-5-public-trust-or-apa-cash-cow">recounted</a> this week by Allen Frances, MD, the editor of the last published DSM edition, the blog’s owner, Suzy Chapman, told him, <i>”On December 22, I was stunned to receive two emails from the Licensing and Permissions department of American Psychiatric Publishing, claiming that the domain name my site operates under was infringing upon the DSM 5 trademark in violation of United States Trademark Law and that my unauthorized actions may subject me to contributory infringement liability including increased damages for willful infringement. I was told to cease and desist immediately all use of the DSM 5 mark and to provide documentation within ten days confirming I had done so." </i><br /><br /><i>"Given my limited resources compared with APA's deep pockets, I had no choice but to comply and was forced to change my site's domain name to <a href="http://dxrevisionwatch.wordpress.com/">dxrevisionwatch</a>. Hits to the new site have plummeted dramatically and it will take months for traffic to recover - just at the time when crucial DSM 5 decisions are being made."</i> <br /><br />In effect, the APA, acting not through its medical or scientific officers but through its wholly owned publishing house, has attempted a SLAPP maneuver. SLAPP is the acronym for strategic lawsuit against public participation. What kind of leadership does this signal in a major professional organization? <br /><br />The normal remit of professional medical societies is stewardship of professional values and ethics. That is why these societies are accorded deference and respect on matters of clinical guidelines, health policy and public education. Even when, like the Institute of Medicine of the National Academy of Sciences, they <a href="http://hcrenewal.blogspot.com/2009/04/institute-of-medicine-report-on.html">tolerate compromised members</a>, they can generally hope to retain the public trust. <br /><br />One reason for this assurance is that they are expected <i>as a matter of professional duty</i> to avoid conflicts of interest – personal and financial. The APA, however, has an enormous conflict in this case: it counts on millions of dollars in revenue from sales of the DSM volumes and it is under siege currently for perceived scientific and clinical weaknesses of the DSM-5 that is due to be released next year. Professional criticism is running so high that over 10,000 interested parties have signed a petition for the APA to reconsider planned changes. There is even talk of abandoning DSM-5 in favor of the ICD system (International Classification of Diseases), which is a WHO initiative. <br /><br />The APA doesn’t own psychiatric classification and diagnostic criteria. When the field allows the APA to take the initiative for revisions of the DSM, it is with the understanding that the work will be conducted in the public interest rather than in the commercial interest of the APA itself, which is said to derive over $5 million annually in profits from DSM sales. The public interest and the public trust are served by transparency and open discussion, not by contrived SLAPP threats. <br /><br />It is bad enough that the APA resorts to this legal artifice to stifle public discussion. When they do it through their lawyers and business entities rather than through their medical and scientific officers, they sink to a lower level yet. The parallels with corporate sleaze that we have discussed so often on this blog are obvious. For shame.

SELF INFLICTED DAMAGE

SELF INFLICTED DAMAGE The American Psychiatric Association (APA) is in the news again for bad public relations: worse than bad, actually – appalling. Locked in a bunker mentality, they have moved to s…

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...THEM OR YOUR LYING EYES?

…THEM OR YOUR LYING EYES? <br /><br />A few days ago I <a href="http://hcrenewal.blogspot.com/2011/04/who-you-gonna-believe.html">discussed</a> stonewalling by the American Psychiatric Association over charges that they were partners in a ghostwritten textbook. The issue resonated with many people, including <a href="http://carlatpsychiatry.blogspot.com/2011/04/like-bad-penny-nemeroffschatzberg.html">Daniel Carlat</a>, <a href="http://1boringoldman.com/index.php/2011/04/05/still-on-the-radar-screen/">John Nardo</a>, <a href="http://pogoblog.typepad.com/pogo/2011/04/ghostwriting-controversy-haunting-the-american-psychiatric-association.html">the POGO blog</a>, <a href="http://alison-bass.blogspot.com/2011/04/tale-of-censorship-and-secrecy-starring.html">Alison Bass</a>, <a href="http://www.pharmalot.com/2011/04/american-psychiatric-association-and-ghostwriting/">Ed Silverman</a>, and others. The APA has not seen its way clear to releasing key documents that might clear up the charges. By stonewalling, the APA just does more damage to its image and credibility. They come across as uninterested in transparency, and they appear to be fighting a rearguard action to defend the indefensible. <br /><br />What kind of key documents could the APA have released? In our <a href="http://pogoblog.typepad.com/pogo/letter-to-apa-20110128.html">letter</a> last January we suggested several, including the contract involving the American Psychiatric Press, the medical communications company (Scientific Therapeutics Information, Inc. or STI), the grant-giving drug company, the professional writers, and the nominal authors of the allegedly ghostwritten book. What might the contract have told us? Well, it probably looks a lot like <a href="http://www.healthyskepticism.org/files/docs/gsk/paroxetine/study329/19980403STIContract.pdf">this contract</a>, which involves the same medical communications company, the same drug company, and one of the same professional writers, Sally Laden. It was developed right around the same time as the textbook was planned, and it is for a ghostwritten journal article promoting the infamous Paxil Study 329. Look carefully at <a href="http://www.healthyskepticism.org/files/docs/gsk/paroxetine/study329/19980403STIContract.pdf">this contract </a>and you will be in no doubt about who did the essential work of writing and framing the article or about whether the corporation had control over the content. Now ask yourselves, if the contract for the textbook <i>doesn’t</i> look like this then why ever would the APA want to suppress it? That behavior just makes people conclude that the contract for the textbook <i>does</i> look like <a href="http://www.healthyskepticism.org/files/docs/gsk/paroxetine/study329/19980403STIContract.pdf">this contract </a>and that the APA knows it has plenty to hide. <br /><br />A first principle of cover-ups and stonewalling is that everyone needs to be on the same page with the cover story. When they are not, the façade collapses and the actors come across like the Three Stooges, all heading for the door at the same time. Today, thanks to the sleuthing of Phyllis Vine at Mental Illness Watch, we saw the stooges exposed in their clumsiness. Phyllis Vine discovered <a href="http://www.miwatch.org/2011/04/apas_ghostwriting_controversy_grows.html">material</a> on the corporate website of STI that has them featuring the textbook in the ‘portfolio’ that aims to attract new business to the company. Juxtapose that with the adjacent claim that STI’s skills are to "develop, write, edit, and submit a high-quality article to your target audience." Now is there any doubt about how this game is played? Now is there any doubt about whether the APA has come clean? <br /><br />Well, if there were any remaining doubt it has been removed by another development: All the materials describing the STI ‘portfolio’ have been removed from the company’s website. Fortunately, Phyllis Vine had captured it <a href="http://www.miwatch.org/2011/04/apas_ghostwriting_controversy_grows.html">here</a>, and so did <a href="http://carlatpsychiatry.blogspot.com/2011/04/new-smoking-gun-in-apa-textbook-fiasco.html">Daniel Carlat </a>through the <a href="http://replay.waybackmachine.org/20081121071704/http:/www.stimedinfo.com/results02_publications.htm">Wayback machine</a>. It was picked up some more by Mickey Nardo <a href="http://1boringoldman.com/index.php/2011/04/11/csi-miwatch/">today</a>. It looks like the APA is going to have more explaining to do. <br /><br />As the old Groucho Marx line goes, Who you gonna believe, them or your lying eyes? <br /><br />Bernard Carroll

...THEM OR YOUR LYING EYES?

…THEM OR YOUR LYING EYES? A few days ago I discussed stonewalling by the American Psychiatric Association over charges that they were partners in a ghostwritten textbook. The issue resonated with many…

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WHO YOU GONNA BELIEVE?

WHO YOU GONNA BELIEVE? <br /><br />Ghostwriting Charges and Stonewalling at the American Psychiatric Association <br /><br />The American Psychiatric Association came under a searchlight this past December over allegations of ghostwriting. The story originated with a public <a href="http://www.pogo.org/pogo-files/letters/public-health/ph-iis-20101129.html">letter</a> from Project on Government Oversight (POGO) to the Director of NIH, and it was picked up by Duff Wilson writing in the <a href="http://www.nytimes.com/2010/11/30/business/30drug.html?_r=3">New York Times</a>. The book was <i>Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care</i>. The named authors were Charles Nemeroff, now chairman of psychiatry at the University of Miami, and Alan Schatzberg, formerly chairman of psychiatry at Stanford University. Both are well known for ethical controversy – see <a href="http://hcrenewal.blogspot.com/search?q=Nemeroff">here</a> and <a href="http://hcrenewal.blogspot.com/search?q=Schatzberg">here</a>. Soon, these allegations were being dissected in the blogosphere, with stellar contributions from <a href="http://carlatpsychiatry.blogspot.com/2010/11/its-textbook-its-ad-its.html">Daniel Carlat</a>, <a href="http://1boringoldman.com/index.php/2011/01/21/when-charlie-met-sally/">1boringoldman</a>, <a href="http://www.pharmalot.com/2010/11/ghostwriting-from-medical-journals-to-entire-books/">Ed Silverman</a>, and <a href="http://alison-bass.blogspot.com/2010/12/government-oversight-agency-calls-on.html">Alison Bass</a>. <br /><br />The APA and its publishing arm, known as American Psychiatric Press, Inc. or APPI, came to the defense of the two prominent academic authors over the ghostwriting charge. In particular, an APA employee named Mark Moran authored a <a href="http://pn.psychiatryonline.org/content/46/2/1.1.full">denial </a>of the charge in the January 2011 issue of the APA news magazine, <i>Psychiatric News</i>. As the controversy played out, letters from attorneys demanded retractions, and partial qualifications of the original story appeared in the New York Times and on the POGO weblog. There was never any doubt that the heavy lifting was done by a pair of professional writers employed by a medical communications company under a financial grant from a drug company. Nemeroff defended his role by averring that he ‘scrutinized’ the work product of the professional writers. Threatening letters from lawyers for Nemeroff and Schatzberg were publicized, and the APA weighed in.<br /><br />The <i>coup de grâce</i> was administered by blogger Daniel Carlat’s withering <a href="http://carlatpsychiatry.blogspot.com/2010/12/nemeroff-and-schatzbergs-textbook.html">review</a> of the book’s artful construction to highlight the use of the sponsoring company’s antidepressant and anti-anxiety drug in primary care, while muting important information about the drug’s liabilities. Nevertheless, the APA held to its legalistic stance in defense of the ‘authors.’ This behavior is counterproductive for professional medical organizations, as I have discussed <a href="http://hcrenewal.blogspot.com/2010/12/impeachment-its-about-institution-not.html">before</a>, because it misses the ethical forest for the legal trees. <br /><br />Now comes the good part. In response to the piece by Mark Moran in <i>Psychiatric News</i>, Leemon McHenry prevailed on Robert Rubin and myself to write with him to the magazine’s editors. Leemon is a faculty member in the Department of Philosophy at California State University, Northridge. He also has experience evaluating legal documents arising in litigation over antidepressant drugs. Robert Rubin has partnered with me in outing several notable ethics compromises involving Nemeroff and Schatzberg, going back as far as 2002, though we always call ourselves equal opportunity critics. <br /><br />Our letter sent in late January to Dr. Carolyn Robinowitz, the Interim Editor of Psychiatric News, has been <a href="http://pogoblog.typepad.com/pogo/letter-to-apa-20110128.html">posted</a> today on the POGO site. In our letter, we challenged much of Mr. Moran’s defense, and we called attention to what WASN’T in the public domain, despite all the claims and counterclaims. Essentially, the partial qualifications of the original reports that appeared in The New York Times and in the letter to NIH from POGO resulted from the inconclusiveness of some of the documents. We called on the APA to come clean with the release of all relevant materials, in the interest of transparency. <br /><br />For instance, what WASN’T known were the specifics of the contract involving the corporation, the (ahem) authors, the publisher (APPI), and the medical communications company. Or the money flow to the ‘authors’ from the contract in addition to their royalties. Or the legal release form transferring ownership of the work product to the ‘authors’ and APPI. Or the corporation’s planned marketing activities, given that the corporation ordered 10,000 copies of the book. Or the correspondence among all parties that might reveal who actually did what. <br /><br />Leemon McHenry’s perspective is that this hidden layer of documents may well be available if they could be unsealed in pending litigation. Naturally, corporations and their attorneys strive to keep the information hidden. But our general point is that the APA has a different duty – which is to transparency rather than to stonewalling. Did the APA do that? Sadly, no, they did not. Here is the curt <a href="http://pogoblog.typepad.com/pogo/apa-response-20110322.html">reply</a> from the Executive Editor Catherine Brown denying publication of our letter after a delay of almost 8 weeks. Now that’s what I call stonewalling.

WHO YOU GONNA BELIEVE?

WHO YOU GONNA BELIEVE? Ghostwriting Charges and Stonewalling at the American Psychiatric Association The American Psychiatric Association came under a searchlight this past December over allegations o…

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INSEL and NEMEROFF - WHAT SANCTIONS?

INSEL and NEMEROFF – WHAT SANCTIONS?<br /><br />Thomas Insel, Director of NIMH, has another <a href="http://www.nimh.nih.gov/about/director/2010/more-on-public-trust-and-conflict-of-interest.shtml">posting</a> in his own defense on his official blog today. He has been widely <a href="http://http//hcrenewal.blogspot.com/2010/06/public-trust-at-nimh.html">criticized</a> lately for the appearance of cronyism in his relationship with Charles Nemeroff. For the past three months, Insel has been trying to put some distance between himself and Nemeroff, but the public isn’t buying it. I have called his statements disingenuous <a href="http://hcrenewal.blogspot.com/2010/04/quis-custodiet-ipsos-custodes.html">here</a> and <a href="http://www.miamiherald.com/2010/06/10/1672327/senator-tells-um-hes-troubled.html">here</a>. Dr. Insel’s statements today are equally disingenuous. <a href="http://1boringoldman.com/index.php/2010/06/15/de-barred-not-a-bad-idea/">Negative reactions</a> are already appearing from those familiar with Nemeroff’s history.<br /><br />There is no argument that Nemeroff was instrumental in Insel’s move to Emory in 1994, that Nemeroff was Insel’s department chairman at Emory, that Nemeroff helped Insel again when Insel’s initial term as director of the Yerkes laboratory at Emory was not renewed in 1999, or that Nemeroff lobbied for Insel’s appointment as NIMH Director in 2002. There is no argument that Insel and Nemeroff have given <a href="http://hcrenewal.blogspot.com/2010/04/quis-custodiet-ipsos-custodes.html">glowing public recommendations </a>of each other, or that they have a record of <a href="http://www.pharmalot.com/2010/06/can-the-nih-really-monitor-conflicts-of-interest/">cozy personal communications</a>. There is no doubt that Pascal Goldschmidt at Miami sought and received a recommendation from Insel before hiring Nemeroff last year or that Insel went out of his way to put a personal gloss on the official NIH position regarding Nemeroff’s eligibility for grant funding if he left Emory. These are matters about which Dr. Insel prevaricates today in his blog.<br /><br />Continuing his prevarication, Dr. Insel today also avoids confronting the issue of Nemeroff’s continuing service on NIMH review committees under Insel’s watch during the period that he was under sanction by Emory University, and banned from participating in NIH grants – before he relocated to Miami. Nemeroff’s <i>curriculum vitae</i> on the U Miami website states that he is a member of the NIMH Review Group, <i>Interventions Committee for Adult Mood and Anxiety Disorders (ITAV), 7/1/2006 - 6/30/2010</i>. This means Insel allowed Nemeroff to continue in that peer review role even though he was banned by Emory from association with NIH grants. The question is why? And what does that tell us about Insel's judgement?<br /><br />It gets worse. During the period that Nemeroff was at Emory and under sanction vis à vis NIH grants, he continued to function as operational director of a NIMH-funded program administered by the American Psychiatric Association (APA). It is inconceivable that Insel was not aware of this arrangement. The APA program is known as Research Colloquium for Junior Investigators, and it is funded through NIMH project # 5R13MH064074-10. For the past few years Nemeroff, as Chair of the APA Committee on Research Training, has directed this program. The nominal Principal Investigator is Darrel Regier, who is the Executive Director of the American Psychiatric Institute for Research and Education (APIRE). At the session in New Orleans during the annual APA meeting last month, one of the featured speakers was Bruce Cuthbert, PhD, one of Insel’s principal lieutenants. In God’s name, why is the APA fronting the compromised Nemeroff as a role model to junior investigators, and why does NIMH/Insel allow this unsavory arrangement to continue? Could it be that Nemeroff’s crony <a href="http://hcrenewal.blogspot.com/2008/08/follow-money-part-ii.html">Alan Schatzberg</a>, the outgoing president of the APA, ran interference for his friend? And what will the new APA president Carol A. Bernstein do about it?<br /><br />And then there is the issue of Nemeroff’s appointment to two new NIMH review committees just recently. Dr. Insel prevaricates again about his awareness or approval of those actions. As reported by Paul Basken in the <a href="http://chronicle.com/article/While-Revising-Ethics-Rules/65800">Chronicle of Higher Education</a>, <i>“An NIH spokesman, John T. Burklow, answering written questions about the matter, confirmed Dr. Nemeroff's full eligibility for agency activities and said he will begin serving this coming week on two scientific panels that review NIH grant applications.”</i> Here again, Dr. Insel seems to be trying to help his crony Nemeroff to get back into circulation after his fall from grace at Emory.<br /><br />Emory University went through the wringer to discipline Nemeroff, at long last, in 2008. The actions of Insel in running interference for Nemeroff’s rehabilitation must leave Emory perplexed. Are Dr. Insel’s statements today disingenuous? You bet. Isn’t it time for the adults at NIH to step in and end this farce?

INSEL and NEMEROFF - WHAT SANCTIONS?

INSEL and NEMEROFF – WHAT SANCTIONS?Thomas Insel, Director of NIMH, has another posting in his own defense on his official blog today. He has been widely criticized lately for the appearance of cronyi…

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