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32, NO. 5
Psychiatrists Betraying Their Patients?
doctors give us psychiatric drugs, are they giving us an
unhealthy quick fix--and making a bundle off of it?
Prominent psychiatrists debate this explosive issue.
LOREN MOSHER RECENTLY RESIGNED IN DISGUST from the
American Psychiatric Association, claiming that some of
his colleagues are too quick to hand out drugs in what he
terms an "unholy alliance" between
psychiatrists and drug companies. A substantial number of
cases of misdiagnosis and fraud support his view that
patient care may be in jeopardy.
not everyone agrees. Frederick Goodwin, M.D., host of
radio's The Infinite Mind and a former director of the
National Institute of Mental Health, counters that
volumes of research and thousands of real-life stories
long ago confirmed the value of prescription drugs for
psychological problems. And he has the establishment
behind him. Providing testimony are the American
Psychiatric Association, the principal professional
association of psychiatrists in the country; the National
Institute of Mental Health, the federal government's
policy and research organization; and the National
Alliance for the Mentally Ill, the nation's largest
advocacy group for the mentally ill.
OF CONTENTS (ToC)
Loren R. Mosher,
MD:"I Want No Part of It Anymore";
Institute of Mental Health
Association for the Mentally Ill
Dr. Mosher is the
director of Soteria Associates, San Diego, and a Clinical
Professor of Psychiatry, School of Medicine, University
of California at San Diego, California.
trouble began in the late 1970s when I conducted a
controversial study: I opened a program -- Soteria House
-- where newly diagnosed schizophrenic patients lived
medication-free with a young, nonprofessional staff
trained to listen to and understand them and provide
companionship. The idea was that schizophrenia can often
be overcome with the help of meaningful relationships,
rather than with drugs, and that such treatment would
eventually lead to unquestionably healthier lives.
experiment worked better than expected. Over the initial
six weeks, patients recovered as quickly as those treated
with medication in hospitals.
results of the study were published in scores of
psychiatric journals, nursing journals and books, but the
project lost its funding and the facility was closed.
Amid the storm of controversy that followed, control of
the research project was taken out of my hands. I also
faced an investigation into my behavior as chief of the
National Institute of Mental Health's Center for Studies
of Schizophrenia and was excluded from prestigious
academic events. By 1980, I was removed from my post
altogether. All of this occurred because of my strong
stand against the overuse of medication and disregard for
drug-free, psychological interventions to treat
soon found a less politically sensitive position at the
Uniformed Services University of the Health Sciences in
Maryland. Eight years later, I re-entered the political
arena as the head of the public mental health system in
Montgomery County, Md., but not without a fight from
friends of the drug industry. The Maryland Psychiatric
Society asked that a state pharmacy committee review my
credentials and prescribing practices to make sure that
Montgomery County patients would receive proper----read:
drug----treatments. In addition, a pro-drug family
advocacy organization arranged for more than 250 furious
letters to be sent to the elected county executive who
had hired me. Fortunately, my employers were not
drugindustry-dominated, so I kept my position.
does the world of psychiatry find me so threatening?
Because drug companies pour millions of dollars into the
pockets of psychiatrists around the country, making them
reluctant to recognize that drugs may not always be in
the best interest of their patients. They are too busy
enjoying drug company perks: consultant gigs, research
grants, fine wine and fancy meals
companies pay through the nose to get their message
across to psychiatrists across the country. They finance
symposia at the two predominant annual psychiatric
conventions, offer yummy treats and music to
conventioneers, and pay $1,000-$2,000 per speaker to hock
their wares. It is estimated that, in total, drug
companies spend an average of $10,000 per physician, per
year, on education.
of course, the doctors-for-hire tell only half the story.
How widely is it known, for example, that Prozac and its
successor antidepressants cause sexual dysfunction in as
many as 70% of people taking them?
even scarier is the greed that is directing a good deal
of drug testing today. It is estimated that drug
manufacturers have, on average, 12 years to recoup
costs and make profits on a given medication before a
generic form can be made. So pressure to test new drugs
mounts. In the field of psychiatric drug testing,
organizations make a profit of as much as $40,000 for
every patient who successfully completes a trial. And
university psychiatry departments, private research
clinics and some individual doctors live on this money.
The good news is that
the press is catching on. The New York News,
Milwaukee Journal Sentinel and New York Post have
recently run articles or series on how pharmaceutical
companies use cash incentives to encourage doctors to
prescribe their drugs.
spring, the New York Post revealed that Columbia
University has been cashing in. Its Office of Clinical
Trials generates about $10 million a year testing new
medications--much of which is granted to the Columbia
Psychiatric Institute for implementing these tests. The
director of the institute was being paid $140,000 a year
by various drug companies to tour the country promoting
their drugs. He also received payments of nearly $12,000
from a drug manufacturer to head up a study on panic
disorders. How could he rate these drugs fairly when-his
livelihood was dependent on the success of the drug
manufacturer? The director resigned in the aftermath of
the article's publication.
least one drug company, WyethAyerst Research, has spoken
out against offering cash bonuses and other incentives to
researchers. But company representatives admit it's
difficult to stay competitive when other groups so
eagerly violate ethical concerns.
American Psychiatric Association representing the
majority of psychiatrists in America, with about 40,000
members--is also unduly influenced by pharmaceutical
dollars. The Association:
- receives substantial rent
from drug companies for huge symposia spaces at
- derives an enormous
percentage of its income from drug companies--30%
of its total budget is from drug company
advertising in its many publications.
- accepts a large number of
unrestricted educational grants from drug
relationship is dangerous because researchers and
psychiatrists then feel indebted to the drug companies,
remain biased in favor of drug cures, downplay side
effects and seldom try other types of interventions. And
they know they have the unspoken blessing of the APA to
these practices aggressively promote reliance on
prescription drug use -- so much so that many people think
drugs should be forced on those who refuse to take them.
The APA supports the National Alliance for the Mentally Ill, which believes that mentally ill patients should be
coerced to take medication. I am appalled by this level
of social control. Mentally ill people should be given a
choice to have their illness treated in alternative ways.
the last decade, I have written a number of letters
bringing my concerns to the APA's attention but have
received no response. The association claims that what it's
doing is in the "best interest of patients,"
but its strong ties to the drug industry suggest
it was dues-paying time for the APA, and I sat there
looking at the form. I thought about the unholy alliance
between the association and the drug industry. I thought
about how consumers are being affected by this alliance,
about the overuse of medication, about side effects and
about alternative treatments. I thought about how
irresponsibly some of my colleagues are acting toward the
general public and the mentally ill. And I realized, I
want no part of it anymore.
The Other Side:
Response by Frederick K. Goodwin, M.D.
Dr Goodwin is a
professor of psychiatry at the George Washington
University Medical Center and former director of the
National Institute of Mental Health.
has seized onto the recent press interest in the
relationship between the pharmaceutical industry and
biomedical professionals as an opportunity to re-open a
25-year-old argument--one that has long been settled by a
mass of scientific evidence and by the testimony of
hundreds of thousands of their families and their
caregivers. The availability of safe and effective
psychoactive drugs has dramatically improved the lives of
millions of individuals with major mental disorders such
as schizophrenia, bipolar illness, clinical depression,
obsessive-compulsive disorder and panic disorder.Dr.
Mosher apparently still sees the issue as a choice
between medications and psychological treatment (he says,
"Schizophivnia, can often be overcome with the help
of meaningful relationships rather than with drugs"),
the overwhelming majority of mental health professionals
now know that for the seriously mentally ill effective
medication makes it possible for psychosocial
interventions to work. And work they do. Many well-controlled
studies have shown that psychosocial treatments combined
with medication can produce substantially better results
than medication alone.
is now so well-established that illnesses such as
schizophrenia and bipolar disorder generally require
medication, that many countries no longer allow a placebo
group in clinical trials with these disorders.
Incidentally, Mosher's 1970s "study" purporting
to compare "meaningful relationships" with
medication was no such thing. A true scientific inquiry
would have required a single pool of patients randomly
assigned to either psychotherapy or drug groups. The
report was simply an interesting description of their
experience with a group of patients who, at least in the
short run, did not seem to require medication.
would have us believe that the very broad consensus about
the importance of medications is somehow the result of
drug company money.
that to the parents of a schizophrenic son who, following
treatment with a new, atypical neuroleptic drug, is able
to hold a job for the first time, to form meaningful
relationships, in short, to reconnect to life.
that to the patients who run the National Depressive and
Manic-Depressive Association, for whom medication, often
combined with psychotherapy, has made the difference
between a shadow-like existence on the margins of life
and the high-level functioning necessary to sustain a
that to the thousands of social workers, psychologists
and psychiatrists who work with the seriously mentally
ill every day and who know from their own experience that
without medications, their patients could not engage with
them in the difficult psychological work of recovery.
forget that before the psychopharmacology revolution, our
state hospitals were filled with hundreds of thousands of
individuals trapped in their psychosis, the victims of
what modern research has clearly shown to be brain
disorders. Today only the tiniest fraction of the
mentally ill still require involuntary hospitalization.
Why? Primarily because of modern medications. Throughout
the long history of psychiatry and psychology during the
pre-drug era, countless heroic efforts to treat severe
mental illness with psychotherapy alone ended in
frustration, a frustration keenly felt by patients,
families and caregivers alike.
suggests that the pharmaceutical industry is a monolithic
force. In reality, a variety of drug companies compete
with one another for market share, and clinicians seem to
be able to sift through competing claims and
our ability to treat these disorders has improved
dramatically over the last 30 years, there is still much
to be done. The development Of novel drugs will continue
to be essential to improving treatment options.
Pharmaceutical innovation depends on lively competition
in the industry, adequate capitalization of what is a
high-risk business and, most importantly, a close working
relationship between industry, government and academia.
The procedures and safeguards needed to ensure the
integrity of this process require continued discussion.
But it needs to be conducted seriously.
Read Letter from
Mosher to Goodwin
correcting errors in the above article. Goodwin has not
Advocate For the Patient and For Quality Treatment" (Up to ToC)
James Thompson, M.D.,
is the deputy medical director of the Office of Education
at the American Psychiatric Association.
Dr Mosher raises an
issue of great concern for all of medicine: the
commercial influence on medical education.
The APA supports the
rigorous stands taken by both the American Medical
Association and the Accreditation Council for Continuing
Medical Education (ACCME) in this area, and has
instituted a careful review and monitoring process,
ensuring that sessions supported by the pharmaceutical
industry at our meetings present solid scientific
information in an unbiased manner
We control all aspects
of this process: We choose the topics and the speakers,
and we control the logistics and evaluation.
sessions represent only a small percentage of the program
and are routinely well-attended and highly rated for
scientific content and lack of bias. Companies are
charged a fee (though not "rent," as the writer
indicates), much of which covers the cost of reviewing
and monitoring the presentations.
No advertising is
permitted and the company's name is mentioned as required
by the ACCME guidelines. It would be pointless to exclude
industry from our meetings altogether because this would
empower them; they would set up independent symposia at
the time and location of our meetings, but outside of our
In addition, throughout
APA programs and publications, nonpharmaceutical
treatmentsfor mental disorders are explored, emphasized
and, in many cases, recommended.
A major APA commission
focuses on the application and efficacy of psychotherapy.
Our practice guidelines -- prepared with no commercial
support whatsoever -- include recommendations on
psychotherapy and other nonmedication-based treatments,
and we continue to recommend psychotherapy training for
residents. As with any medical specialty, our members
have varying attitudes about treatment modalities, but
the APA supports the use of a wide variety of therapeutic
options geared toward the needs of the particular patient
and continues, above all, to advocate for the patient and
Response by the National Institute of Mental Health:
Time for Helplessness And Bitterness Is Past" (Up to ToC)
Steven E. Hyman, M.D.,
is the director of the National Institute of Mental
It would be tragic if
Dr Mosher's personal history prevented anyone with mental
illness from obtaining effective treatment. In the years
since Mosher has been active in research, a revolution
has occurred. In place of medications with questionable
efficacy and major negative side effects, or unproven and
expensive psychotherapies, we now have a variety of safe
and effective medications and psycho'therapies for mental
The National Institute
of Mental Health, with public funds, has overseen this
quiet revolution and has funded its own studies to make
sure that the new mood stabilizers, antidepressants and
antipsychotics work for Americans with mental illness.
While much remains to be done, the time for helplessness
and bitterness is past.
People Should Have The Right to Make Their Own Decisions" (Up to ToC)
William Emmet is
the chief operating officer of the National Alliance for
the Mentally Ill.
For the record, the
National Alliancefor the Mentally Ill (NAMI) focuses
primarily on ensuring access to adequate, appropriate
treatment within the American health care system. As a
matter of Policy, it does not endorse any particular
treatment or services for brain disorders. NAMI believes
that all people should have the right to make their own
decisions about medical treatment, but is aware that some
individuals with brain disorders such as schizophrenia
and bipolar disorder may at times, due to their illness,
lack insight or good judgment about their need for
medical treatment. Involuntary treatment of any kind
should be used only as a last resort and only when it is
believed to be in the best interest of the individual,
following a court hearing in which due process has been
provided. Outpatient treatment also should be considered
the most beneficial, least restrictive and least costly
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