Wednesday, October 04, 2006

CPP Manifesto

I was just sending an email and I got to ranting a little bit. I am reproducing that email here in edited and expanded format because I think it represents the manifesto of this site.

It seems to border on amazing that tens of billions have been spent on developing meds for depression, schizophrenia, anxiety, and bipolar disorder, as well as many other psychiatric conditions, yet in nearly all cases, the meds we have now are no more efficacious than meds designed 50 years ago. Spending less time on developing me-too meds would be a good start. How many atypical antipsychotics are really necessary? How many SSRIs really need to be on the market? Allocating fewer resources to marketing and more to research wouldn't hurt either.

Hopefully one or more among us can help improve upon 50 years of meager progress in psychiatric treatments. I'd add that, despite the hype, clinical/counseling psychology hasn't exactly done a great job of developing therapies that add much beyond already existing treatments. As with my prior comment about SSRIs, how many variants of cognitive-behavior therapy do we need? How many times will we compare various therapies to each other in studies to come to the underwhelming conclusion that therapy which is intended to be effective is better than therapy that is not intended to work, but essentially all therapies that are based on a credible rationale and are intended to work yield equivalent outcomes (see research from Bruce Wampold). We know that monitoring outcome more closely and regularly improves outcome in psychotherapy (see Michael Lambert et al's research if you need proof), yet few clinicians bother to monitor outcome in any systematic fashion, if they record outcome at all.

Perhaps I'll feel more optimistic later, but the current state of affairs in both psychiatry and psychotherapy seems more hype than help, with psychiatry being the greater of the two offenders. Given that psychiatry has many more financial resources to develop treatments than does psychology, one would expect that psychiatric treatments would be superior, but such has rarely proven to be the case when medications are compared to psychotherapy in head to head trials. Indeed, the opposite is often true, especially in the long-term (most notably for depression and anxiety). Yes -- I realize that meds are standard treatments for bipolar and schizophrenia, but psychotherapy has shown some promise in these areas, and neither meds nor therapy are associated with very impressive long-term outcomes for bipolar or schizophrenia. Let me state clearly that treatment often works -- I'm not pulling a Tom Cruise here -- but that there has been a pathetic amount of progress made in improving mental health outcomes in proportion to the time and money spent on research.

Shame on individuals and companies who do not contribute to improved treatment outcomes. Companies that bury or distort trial data are shameful. Hiding safety data to make drugs falsely look safe and/or inappropriately attributing adverse events to placebo (among a laundry list of poor practices) is beyond reprehensible. Academic researchers who let their industry-provided cash cloud their judgment – double dishonor on you. Yes, we all make mistakes, but when a conflict of interest is present, we should do our damndest to at least maintain an image of propriety! All mental health practitioners that do not attempt to demonstrate the effectiveness of their individual work (i.e., does treatment, as I provide it, work to alleviate symptoms and improve the quality of life of my patients) – you’re part of the problem as well. Yes, the type of patients you serve of course impacts their outcomes and your ability to measure them, but by God, you should certainly try your best to incorporate some sort of individual accountability to make sure your patients are improving at a reasonable rate. I’m not endorsing pay for performance or any other buzzwords, just suggesting strongly that clinicians pay close attention to their outcomes, since that is the bottom line reason why they have clinical jobs in the first place.

OK, I suppose I’ve officially hit “diatribe mode,” so I’ll sign off with the above as the official manifesto of the site. Please comment if you think I’m losing my marbles or if you think “right on” or somewhere in between.

4 comments:

N.A.B. said...

Right on. . .

I am a neurochemist-turned-attorney, who has not been in a lab for 6 or 7 years, but who knows exactly what is going on. I read everything I can get my hands on (independent research, Angell, Healey, et al.), and frankly, the more I read. . .the more frustrated I become.

I am with you though. . .keep at it.

CL Psych said...

N.A.B.,

There is indeed much to cause frustration. If we can somehow get people to pay closer attention to evidence and less attention to hype and marketing, positive change is possible. Shaming corporations, researchers and "opinion leaders" who are leading the mental health profession (as well as medicine as a whole) astray also seems a logical part of instigating change. Keep the faith!

N.A.B. said...

I've thought long and hard on this and I agree: public shame, scorn, and ridicule are really the only viable avenues of change.

Honestly, the "medical profession" - as a whole - has a duty to step up to the plate on this issue and police themselves. It is certainly in their best interest to do so ASAP because ultimately it is their credibility that all of these entities (pharma, the hospitals, device makers, and the doctors themselves) are exploiting/undermining for profit.

Knowing that there are countless noble physicians and scientists out there only makes the complicity of silence worse: the entire profession is and will be held accountable when the proverbial fan is hit. It should be obvious that professional autonomy is what is ultimately at risk.

Best to go ahead and clean house now, but too many people seem too vested. At the end of the day, however, you can only piss in a cup and tell people it is wine for so long.

CL Psych said...

But will the medical profession police itself when they generally tend to believe that while their fellow professionals are gullible fools who are manipulated by ads and drug reps, they themselves are not subject to the same influences? Unfortunately, docs don't see themselves as manipulated by these corrupting influences.

I think that many of the noble professionals of whom you speak believe that if their practice is ethical, then they are not responsible for any of the effects of poorly allocated resources, corruption, and greed. "If I'm doing my job right, I don't need to worry about what's happening around me." The path of least resistance is the easiest to choose. Being a whisteblower is not a good way to make friends.

Perhaps things need to get much worse for an outcry to occur. That or the media could do a much better job of reporting on what is going on currently and many people's eyes would likely spring out of their sockets in amazement. However, if you watch the evening news, most of the ads seem to be for drugs, so it is likely not in the media's best financial interest to conduct serious investigations on a regular basis into the often nefarious practices in the drug industry and affiliated academic researchers. That would certainly cost valuable ad revenue.

To go to your excellent closing metaphor, I hope that people will eventually realize that the wine is indeed something less tasty, but it's sure difficult to do that when they've been told repeatedly by highly regarded people that the two fluids are in fact one and the same.