PSYCHOLOGY TODAY
VOLUME 32, NO. 5
September/October 1999
Are Psychiatrists Betraying Their Patients?
When 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.
PSYCHIATRIST 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.
But 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.
TABLE OF CONTENTS (ToC)
Loren R. Mosher, MD:"I Want No Part of It
Anymore";
RESPONSES FROM:
Frederick K. Goodwin, MD
The American Psychiatric Association
The National Institute of Mental Health
The National Association for the Mentally Ill
Loren R. Mosher, M.D.
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.
The 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.
The experiment worked better than expected. Over the initial six weeks,
patients recovered as quickly as those treated with medication in hospitals.
The 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 psychological disorders.
I 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.
Why 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
Pharmaceutical 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.
And, 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?
What's 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.
This 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.
At, 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.
The APA Connection
The 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
national conventions.
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
companies.
This 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 do so.
Collectively, 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.
Over 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 otherwise.
Recently, 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:
A 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.
Dr.Mosher 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
has
While 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.
It 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.
Mosher would have us believe that the very broad consensus about the
importance of medications is somehow the result of drug company money.
Tell 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.
Tell 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 successful
organization.
Tell 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.
Don't 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.
Mosher 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
counterclaims.
While 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 responded.
"We 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.
These sponsored 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 control.
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 quality treatment.
A Response by the National Institute of Mental Health:
"The Time for Helplessness And Bitterness Is Past"
(Up
to ToC)
Steven E. Hyman, M.D., is the director of the National Institute of
Mental Health.
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 illnesses.
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.
"All 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 treatment
alternative
