Conflict of Interest in Psychiatry – Lecture by Thomas Insel at the 2010 Neuroethics Society Meeting

Thomas Insel, Director of the National Institutes of Mental Health, gave a plenary address to the Neuroethics Society on Saturday entitled “Conflict of Interest in Psychiatry”.  Using data provided by the PharmedOut, a Georgetown University Medical Center-based project that empowers physicians to identify and counter inappropriate pharmaceutical promotion practices, Dr. Insel walked through a series of observations that suggest that psychiatry is particularly heavily targeted, and influenced, by the pharmaceutical industry.  Among the eye-popping observations that were shared were these:

Of 394 physicians who received over $100,000 from the pharmaceutical industry, 116 were psychiatrists, well out of proportion to the percentage of psychiatrists in medical practice.

Antipsychotics are the top-selling class of drugs in the United States, with sales of $14.6B.  What is most remarkable about this observation is that the older antipsychotics, which are no longer protected by patents, are of equal or superior effectiveness to the current crop of second-generation antipsychotics, but physicians prescribe the new ones at a huge cost to society.

An important observation that I had never heard before was that disclosure of conflict of interest is not the same as lack of conflict of interest.  Dr. Insel cited the work of George Loewenstein and his colleagues who report that, Continue reading

Unintended Consequences of Neuroscientific Explanations

René Magritte, Les Amants (1928)

In Madness and Civilization, French philosopher and activist Michel Foucault wrote that, “from the fifteenth century on, the face of madness has haunted the imagination of Western man.” Foucault argues that the concept of ‘madness’, at least in the 1800s, was characterized as a loss of ‘reason’ – the essential mental faculty which made human beings distinct from other animals. Those who lacked reason (which all rational beings possessed) were perceived as a threat to humanity. Eventually barriers were raised – both literally and figuratively – which separated these ‘irrational’ individuals from the rest of humanity.

Such stigmatizing and social-distancing attitudes towards those living with mental illness are still deeply enmeshed in the social and cultural norms of many industrialized nations. In the 1960s, sociologist Erving Goffman spoke of stigma as a “spoiled identity;” more closer to us Bruce Link and Jo Phelan conceptualize stigma as occurring when “elements of labeling, stereotyping, separation, status loss, and discrimination occur in a power situation that allows them.” A related concept, social distance, is defined as the degree of proximity an individual is comfortable with in relation to an individual who is living with mental illness, particularly as it relates to the perceived dangerousness or unpredictability of that individual. Prevailing views amongst the public see the behaviour of individuals living with mental illness as volitional; at times these individuals might be considered ‘lazy’ (in the case of major depression and the ethical values tied to participation in the workforce), and so, intuitions about mental illness are believed to be justified blaming these individuals, or perhaps even punishing them.

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Conference Announcement: Brain Matters II

Just received the following announcement from Dr. Barbara Russell, bioethicist at Toronto’s Centre for Addiction and Mental Health, and coordinator of the Canadian Bioethics Society Neuroethics Interest group.  It has just been announced that the Brain Matters neuroethics conference will be held in Montreal in the spring of 2011. The theme of Brain Matters II appears to have a clinical ethics focus. The first Brain Matters conference occurred September 2009 in Halifax, Nova Scotia and was a great success. Looking forward to the call for abstracts and seeing who the organizers secure for the plenaries.

INTERNATIONAL NEUROETHICS CONFERENCE

BRAIN MATTERS II: Ethics in the Translation of Neuroscience Research to Psychiatric and Neurological Care

Montreal, Quebec, Canada

May 26-27 2011

Call for abstracts forthcoming. For more information, please contact: neuroethics@ircm.qc.ca

Links

Peter Reiner and I wrote a post on our reflections of the first Brain Matters conference: Brain Matters

Brain Matters: New Directions in Neuroethics from Dalhousie’s Novel Tech Ethics website.

IRCM Neuroethics Research Unit

Estimating the Costs of Medicalization

Peter Conrad, a sociologist at Brandeis has been a thoughtful commentator on the phenomenon of medicalization for the past four decades.  His team has just published a new paper in which they estimate the costs of medicalization.  The abstract sums the matters up nicely.

“Medicalization is the process by which non-medical problems become defined and treated as medical problems, usually as illnesses or disorders. There has been growing concern with the possibility that medicalization is driving increased health care costs. In this paper we estimate the medical spending in the U.S. of identified medicalized conditions at approximately $77 billion in 2005, 3.9% of total domestic expenditures on health care. This estimate is based on the direct costs associated with twelve medicalized conditions. Although due to data limitations this estimate does not include all medicalized conditions, it can inform future debates about health care spending and medicalization.”

In the paper, they are careful not to overstate their case, and provide appropriate cautions as to the interpretation of the data, recognizing that classifying indications as medicalized is fraught with subjectivity.  Nonetheless, this is an important contribution to the ongoing debate over the issue, and provides for the first time economic data.  From there, others can dissect the relevancy of the conditions they have chosen as well as challenge and refine their economic analysis.  From our perspective, the paper is timely, especially as the debate over DSM-V and its proposed introduction of dimensional measures continues.

Link to Estimating the Costs of Medicalization by Conrad et al. 2010 (subscription may be required).

Links (here, here, here, here, and here) to previous posts on the DSM-V controversy and medicalization in psychiatry.

Image Credit: Free Press Release

Public expression and DSM-V

The bible of Psychiatry, The Diagnostic and Statistical Manual of Mental Disorders (DSM), is the standard reference text by which psychiatric disorders are classified.  Every now and then, the psychiatric community revises the manual; the current version, DSM-IV was published in 1994 and in 2000 revisions of the text were added (hence the clumsy term DSM-IV-TR) but the categories of psychiatric disease remained unchanged.  At the moment, a committee is hard at work developing a new version, DSM-V, and the issue has morphed from scientific enterprise to public melodrama.

Over at H-Madness, a blog devoted to the history of psychiatry, the historian Hannah Decker has a wonderful post detailing the trials and tribulations of the controversies currently embroiling the production of DSM-V.  Entitled A Moment of Crisis in the History of American Psychiatry, Decker’s post covers all of the usual territory, some of which we have discussed previously (here and here). It bears repeating that the biggest challenge to the endeavour is the lack of objective criteria for defining psychiatric diseases: until neuroscience provides this clinical specialty with concrete insights into the relevant changes in human neurobiology that accompany psychiatric disease, the field will continue to be on shaky ground, defining and redefining ‘syndromes’ composed of constellations of symptoms rather than clearly understood alterations which result in pathology. Continue reading

Psychiatry’s existential crisis

dsm_iv_21Simon Baron-Cohen, the Cambridge psychologist best known for developing the hypothesis that autism is caused by delays in the development of theory of mind, has an op-ed piece in today’s New York Times about the challenges facing the DSM committee as they proceed with developing DSM-V.  Apparently, the committee is considering subsuming autism and Asperger’s syndrome under the single diagnosis of autism spectrum disorder.  Baron-Cohen urges the committee not to do so.

What is notable about his argument is not that autism spectrum disorder does not exist, but rather that we know too little about it to be certain that this is a better way of characterizing the situation.  Without a firmer grasp of the relevant details, Baron-Cohen argues that we should not make changes in the DSM that may have far ranging consequences.  After all, DSM “is the bible of diagnosis in psychiatry, and is used not just by doctors around the world but also by health insurers.”

Later in his article he gets to the meat of the matter:

Part of the reason the diagnostic manual can move the boundaries and add or remove “mental disorders” so easily is that it focuses on surface appearances or behavior (symptoms) and is silent about causes. Symptoms can be arranged into groups in many ways, and there is no single right way to cluster them. Psychiatry is not at the stage of other branches of medicine, where a diagnostic category depends on a known biological mechanism. An example of where this does occur is Down syndrome, where surface appearances are irrelevant. Instead the cause — an extra copy of Chromosome 21 — is the sole determinant to obtain a diagnosis. Psychiatry, in contrast, does not yet have any diagnostic blood tests with which to reveal a biological mechanism.

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What is normal, anyway?

Asperger-Vienna-clinic

Hans Asperger (1906–1980) at work in the University Pediatric Clinic, Vienna performing a psychological test of a child.

Over at the Guardian, there is a delightful piece about an adolescent boy with a form of autism spectrum disorder known as Asperger’s disease. The entire article is worth reading for its insight into the life of an individual with Asperger’s, but one of the most telling lines emerges when the author tells us,

I begin to see what his mother means when she says Asperger’s can be more complex than the stereotypes suggest. “If there was a cure for Asperger’s,” she says, “I wouldn’t want it. Al’s just himself.”

Alex echoes his mother’s comments.

“I don’t think I’ve got a disability. I like being me.”

When patients say that they prefer the situation that they find themselves in, it is worth stopping and asking if the medicalization machine is moving too far too fast.

Hans Asperger first described the phenomenon in 1944, but the diagnosis of Asperger’s did not become official until 1992 when it was included in the International Classification of Diseases (ICD-10); in 1994, it was included in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV.  It is worth quoting from the ICD-10.

A disorder of uncertain nosological validity, characterized by the same type of qualitative abnormalities of reciprocal social interaction that typify autism, together with a restricted, stereotyped, repetitive repertoire of interests and activities. It differs from autism primarily in the fact that there is no general delay or retardation in language or in cognitive development. This disorder is often associated with marked clumsiness. There is a strong tendency for the abnormalities to persist into adolescence and adult life. Psychotic episodes occasionally occur in early adult life.

As it turns out, it seems likely that despite the ICD’s disclaimer of uncertain nosological validity for the diagnosis, there are indeed individuals out there with Asperger’s, and it is important to recognize them.  The important question is whether it should be considered a disease or not.  This question is raging as the field gears up for the arrival of DSM-V (I previously wrote about this here). In a broadside at the process that is being used to develop the new version of DSM, Allen Frances, the individual who chaired the DSM-IV Task Force, argues that the approach being taken is way off track.  The earnest group engaged in the herculean task of revisiting DSM push back. So it goes in academic medicine. [For a definitive historical look at DSM, I highly recommend Christopher Lane's book Shyness.]

What concerns us is not squabbling over process or priority, but rather the impact that all of this has on individuals and society at large.  Amid a number of concerns, Dr. Frances rightly reserves his strongest objection to the potential of DSM-V to further medicalize normalcy.

Undoubtedly, the most reckless suggestion for DSM-V is that it include many new categories to capture the subthreshhold (eg, minor depression, mild cognitive disorder) or premorbid (eg, prepsychotic) versions of the existing official disorders. The beneficial intended purpose is to improve early case finding and promote preventive treatments. Unfortunately, however, the DSM-V Task Force has failed to adequately consider the potentially disastrous unintended consequence that DSM-V may flood the world with tens of millions of newly labeled false-positive “patients.” The reported rates of DSM-V mental disorders would skyrocket, especially because there are many more people at the boundary than those who present with the more severe and clearly “clinical” disorders. The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments—a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net. They will pay a high price in adverse effects, dollars, and stigma, not to mention the unpredictable impact on insurability, disability, and forensics.

Dr. Frances’ goes on to say,

The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V.

So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality.

Here we get to the heart of the dilemma.  The field of psychiatry struggles to help patients, but the truth is that the neurosciences have yet to reveal the causes of psychiatric disorders.  Without objective criteria to guide them, physicians fall back on descriptors which are imprecise and therapies which do not treat the underlying (and still unknown) pathology. Lacking the confidence to distinguish normal behavior from diseased, the field inadvertently medicalizes normalcy.

And Alex, the boy with Asperger’s, finds himself squarely in the crosshairs of this raging dispute.