It is not surprising that American psychiatry embraced science during the last half century. Before that Freud’s ideas and those of his critics dominated the field. While some of their ideas had the ring of truth, and many fine observations were made, the one thing they were not was scientific. Their methodology was not the way to scientifically advance the frontiers of our knowledge.
It eventually didn’t matter. Claims to scientific validity were abandoned. Rejecting much of Freud’s theories, mental health entered an era where the wisdom of Buddha, of Hindu philosophies and practices, spiritual knowledge of all sorts was validation enough. Psychiatrists still retained their position in medical schools, but in the general public, psychobabble held sway. A salad of wishful thinking, where practically any belief was acceptable as long as the rhetoric was inspirational enough, was the measure of truth.
Even before mental health writing deteriorated into a hodgepodge of dramatic solutions for how to live, psychiatry was considered the step child of medicine. There was very little reason to disabuse the other medical specialties of that opinion. Other specialties placed their primary focus on the biological processes that led to disease. It was in biology and chemistry that progress was being made. That was the direction psychiatry had to go if it had any hope of legitimacy. In medical schools throughout the country psychoanalysts were replaced by biological psychiatrists. The remedies in psychiatry soon became the same as in other fields of medicine, pharmaceuticals. There were other treatments, electric shock therapy, and lately, placing the brain in magnetic fields, all kinds of techniques, analogous to surgery. But most psychiatric practice consisted of prescribing drugs. Or cognitive behavioral therapy became acceptable, a variation of behaviorism (which among psychologists had solid scientific credentials). Both strategies aimed for scientific rigor, claiming the prestige that goes with scientific accomplishment. As we will see, both failed miserably to accomplish that goal.
In the mind of the public, the enormous popularity of Prozac and sometimes, it’s almost magical effectiveness, gave the impression that great strides were being made in neurobiology. That wasn’t the case. Swinging blindly, Eli Lilly hit a home run, more than that, a grand slammer with Prozac. And at first, even they didn’t realize what they had discovered. In their labs they first tried Prozac as a blood pressure medicine, then as a weight loss agent. No luck. It also wasn’t impressive treating severe depression. But using it for patients with milder depression gave good results. Serotonin, which is increased by Prozac, was not, at the time, even speculated to be of importance in mental states. When Prozac was marketed, expectations were that it would be a modest success.
Not Eli Lilly, but Pfizer, which developed Zoloft, their own SSRI, claimed those suffering from depression had a chemical imbalance of serotonin in the brain. SSRIs were alleged to fix it. That is not the case. No imbalance was demonstrated at the time and since then all attempts to do so have been fruitless. But it was a great way to explain to patients what the drug was doing. In a study of SSRIs, they were shown to decrease stress induced vocalizations in guinea pig pups. They squeal in a panic when they are separated from their mothers. Prozac lessens these. Regardless of how it works in the brain, if a chemical reduces these vocalizations it may have promise as a psychotherapeutic agent (These are normal guinea pigs not those with a chemical imbalance). A drug successfully screened in this manner will certainly not be presented to patients as a drug so good at shutting off distress that it even works to subdue what might be considered the prototypical model of terror, a helpless infant separated from its mother. A patient told he is being given a drug to kill his reaction to what has been upsetting him will approach that treatment very differently than a patient given a different spin, one told that his medication is treating a chemical imbalance that is causing his ailment. Similarly, primary care physicians will be far more enamored with the thought that an agent has been tested (and even better, FDA approved) for a specific DSM disorder if their mindset is that its effectiveness is due to fixing faulty synapses rather than the patient is being drugged out of his suffering.
When they were given The Discoverers Award for their work, the discoverers of Prozac, Drs. Fuller, Molloy and Wong strongly emphasized how little we understand about the brain and Prozac. That aside, the sales of Prozac skyrocketed. It wasn’t only the simplicity and beauty of the chemical imbalance model that enabled all kinds of doctors to prescribe SSRIs and the widespread belief that amazing progress was being made in neurobiology. Nor was it, as is often charged, the evil marketing of Big Pharma. There was perhaps another factor.
Peter Kramer raised the possibility that Prozac was a “personality enhancer.” In addition to lifting depression, Prozac could also brighten a dull personality, assist an ambitious employee in climbing the corporate ladder, and make a shy person lively and outgoing. Kramer termed the use of drugs in this fashion “cosmetic psychopharmacology”. They were said to make a patient ‘better than well”. There was enormous excitement in the public as patients were noticeably transformed. Many of their colleagues and friends wanted to try the same thing.
Prozac is not the first drug to cause this kind of intoxication. In the 19th century cocaine was the most popular miracle drug in the world, regularly used and extolled by the likes of President McKinley, Queen Victoria, Pope Leo Xlll, Thomas Edison, Robert Lewis Stevenson, Ibsen, Anatole France and a host of other renowned members of society. Sigmund Freud wrote the following about it, “You perceive an increase of self-control and possess more vitality and capacity for work.” According to the Sears, Roebuck and Co. Consumers’ Guide (1900), their extraordinary Peruvian Wine of Coca “…sustains and refreshes both the body and brain…. It may be taken at any time with perfect safety…it has been effectually proven that in the same space of time more than double the amount of work could be undergone when Peruvian Wine of Coca was used, and positively no fatigue experienced.”
The medical cure for ADHD patients’ inability to confront drudgery is stimulants, which are much like cocaine. They have a long history of working pretty well for this purpose. Prescribing them requires a narcotic license but they are widely prescribed for ADHD, and like cocaine, have found widespread uses beyond those diagnosed with an illness. After he read an article I wrote about ADHD, my son, told me about his friend at Yale. One afternoon he was complaining about the work he had before him, two finals and three papers that were due. His roommate piped in, “I got some Ritalin, want it?” The daughter of a friend said the same thing was going on at McGill. They are not alone. Here is a headline from the NY Times:
“Latest Campus High: Illicit use of Prescription Medication, Experts and Students Say”
“Ritalin makes repetitive, boring tasks like cleaning your room seem fun” said Josh Koenig a 20-year-old drama major from NYU.
“Katherine Plyshevsky, 21, a junior from New Milford NJ majoring in marketing at NYU said she used Ritalin obtained from a friend with ADD to get through her midterms “It was actually fun to do the work,” she said.
Freud realized he had made a big mistake advocating the use of cocaine when he witnessed the horrible effects it was having on some of his friends. The downside of this miracle drug was also well described by Robert Lewis Stevenson who wrote Dr. Jekyll and Mr. Hyde during seven days and nights while he was high on cocaine. For many years, Stephen King wrote all of his novels while high on stimulants. He has said that the Kathy Bates character in his “Misery” (a nurse who has literally imprisoned him) represented that habit. It should be noted that after he stopped drugs he described himself as a “TV slut,” I take that to mean that he was no longer willing to buy into the Faustian bargain.
Besides ADHD diagnosed adolescents, and their friends, who sometimes borrow their meds when they have to do chores that they dread, stimulants (“greenies”), according to David Wells, and later Mike Schmidt, long were a part of the professional athletes’ equipment, helping them to step up to the plate with confidence. It changes their state of mind from a passive, reactive, perhaps half defeated position, to a take charge proactive stance. Or as one basketball player put it, “Give me the ball. I can make the shot.” This taking charge, “I can do it” feeling, when approaching tasks, is a key element in most people’s perception of whether they are up to a challenge, and whether it is “work” or pleasurable. This is why it is effective in ADHD, an ailment characterized by an inability to concentrate when work is involved, but no problem in concentrating when an activity is fun.
I had a patient who told me that he could not read more than a paragraph or two of assigned reading from school without his Adderall. “Really?” I commented. “Well,” he answered. “I am really into mountain biking and once a month I get this mountain biking magazine. I tear through that.” He was also not lacking in his ability to pay attention when it came to video games. He was very skillful, quick and focused on them. Over and over I found a similar story in other patients. They contrasted markedly with my mother, who found great joy in sacrificing. The harder the task the greater her pride. Her generation understood the postman’s motto. “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds.” Pleasure comes from meeting the challenge that work presents.
This is foreign to someone with ADHD. Stimulants are the only way they get done what needs to be done.
I do not mean to imply disapproval. Yes, there are a whole lot of children with the diagnosis that can best be described as lazy and n’er do wells, and as adults, ADHD children disproportionately land up in jail. But many other people once diagnosed with ADHD change. As children they may have been nay sayers and rebellious and unable to be interested in the tasks being thrown at them, but later they become famously impassioned by their work and very far from lazy. Pete Rose was a rambunctious youngster who couldn’t sit still in class. Most people wrote him off as a troublemaker. Teachers made an example out of him. Predictably he lost interest in school. Perhaps most or all rebellious children are labelled ADHD because they are so uninterested in doing what they should be doing. But the fact is that no one tried harder, played baseball with as much passion as Pete Rose. He continued to not go along with what he was supposed to do. He gambled, and as a result was banned from baseball, but being able to throw himself into work was not a problem.
It isn’t necessarily rebelliousness. Brazilian American Mormon David Neeleman, the son of grocers had little interest in schoolwork or work in general and today believes he had ADHD. It is true he couldn’t concentrate on school work. He wasn’t able to get up the needed diligence, which concerned him because he was not happy that he was a disappointment to his parents.
He lived in Brazil until he was five, spoke Portuguese with his parents and returned to work in Brazil as a nineteen-year-old, as part of the Mormon tradition. Before that he had worked in his family’s grocery business as a cashier. In Brazil, he spent time with the downtrodden and people who had nothing. The experience inspired him, made him decide to return to Brazil one day and do something to help the people there. He credits his moral zeal with putting an end to his ADHD. Diving into work, doing his studies at school became automatic.
He set up an air service arrangement that accomplished his ideals, working with great passion and dedication. Eventually, he founded Jet Blue with a very unconventional booking system that soon became standard in the industry. Something similar to what happened to Stephen Jobs, when he was forced out of being CEO by Apple’s board, also happened to Neeleman as CEO of Jet Blue. Founder or not, he was shown the door. In addition to making mistakes similar to what others might make, he had too many unconventional ideas, threw caution to the winds too often and repeatedly disagreed with the beliefs of board members.
ADHD? Who knows? Perhaps. But I hope the reader has learned enough about Rose and Neeleman so that we can drop the idea that they were plagued by biology. They weren’t diligent children and, perhaps even, were genetically different than most other people, which has lasted into adulthood. Neither Rose nor Neeleman were treated with medications as a child, but while they may have had the cluster of symptoms describing ADHD, reducing them to a diagnosis with a medication cure would have been a crude response to their troubles. I very much doubt it would have changed their lives for the better.
ADHD is prime example of a disease with an enormous amount of false, often ridiculous scientific articles trying to convince the public and doctors that the problem these patients have paying attention, is biological. Dr. William Pelham, a leading ADHD researcher for 30 years, came forward with this charge. “I have come to believe that the individuals who advocate most strongly in favor of medication – both those from the professional community, including the National Institutes of Mental Health, and those from advocacy groups, including CHADD – have major and undisclosed conflicts of interest with the pharmaceutical companies that deal with ADHD products.”
Dr. Pelham brought forth clear cut evidence of the collusion in his own work. Dr. Pelham was paid by McNeil to conduct one of three studies used to get FDA approval for Concerta, a stimulant prescribed for ADHD. But when the evidence was not favorable, he recounted in an interview with AlterNet, McNeil-Alza engaged in dubious methods to ensure that the published reports would be favorable for Concerta. He said “The company currently uses the three studies to claim that 96 percent of children taking Concerta experience no problems in appetite, growth, or sleep. But Pelham says the studies were flawed… two of the three studies, including Pelham’s, required that the subjects had to already be taking a stimulant and responding well to it in order to enter the study. In other words, by stacking the studies with patients already successfully taking stimulants, McNeil ensured the subjects would be unlikely to register side effects.
Pressure was also brought to bear to shape Dr. Pelham’s written report: When his paper was in the galley proof stage at the medical journal Pediatrics, Pelham says he joined a conference call with a number of senior people from the corporation who lobbied him to change what he had written in the paper. “The people at Alza clearly pushed me to delete a paragraph in the article where I was saying it was important to do combined treatments (medication and behavioral).” That was a no-no because they wanted pediatricians to feel comfortable prescribing the drug without psychotherapy. They also pushed him to water down or eliminate other sentences and words that did not dovetail into their interests. “It was intimidating to be one researcher and have all these people pushing me to change the text.” In the end, Dr. Pelham says, they published a report with his name penned to it without his authorization.
The most prominent and outspoken advocate for the biological origin of ADHD is Dr. Joseph Biederman MD, (Professor of Psychiatry at Harvard Medical School. Chief, Clinical and Research in Pediatric Psychopharmacology Massachusetts General Hospital and McLean Hospital).” He is the author and co-author over 800 “scientific” articles, 650 scientific abstracts, and 70 book chapters.” In October 2007, Dr. Biederman was ranked as the second highest producer of high-impact papers in psychiatry overall throughout the world by the Institute for Scientific Information (ISI). The same organization ranked Dr. Biederman at #1 in terms of total citations to his papers published about ADD/ADHD in the past decade. In 2014, Thompson Reuters named Dr. Biederman on their list of The World’s Most Influential Scientific Minds, as ranking in the top 1% by citations for the field of psychiatry. He has been inducted into the Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) hall of fame. Dr. Biederman is a grant reviewer in the Child Psychopathology and Treatment Review Committee of the NIMH. So, of all people Dr. Biederman presumably knows a lot about ADHD despite, I assume, given his academic churning, he had very little time to see actual patients. My only awareness of Dr. Biederman came from almost monthly mailings sent to me, and most likely, every physician who was on the mailing list of medical journals. The message was hammered home: ‘Are you missing your patients with Adult ADHD. It was a new market with vast potential to be won over.
Many children move beyond their illness when they find a career that turns them on. Predictably, biological psychiatrists claimed the change occurs because the brain physically matures. Whatever the explanation, some patients don’t grow out it and continue their meds so adult ADHD was often diagnosed. Beyond that numerous celebrities announced to the world that they had the illness, Michael Phelps, Simone Biles, Paris Hilton, Justin Timberlake and many others told the public that they have ADHD. Simone Biles, said by some to be the greatest gymnast of all times, presented an interesting case. She was taking Ritalin while she competed in her historic 2016 Olympic performance. It was found on drug screening and as a performance enhancer it would ordinarily strip her of her gold medals. Apparently, she was allowed to keep them because it was a medical treatment.
In addition, a new form of Adult ADHD emerged, those who had not been thought to have had ADHD as children. Patients like Terry Bradshaw, former quarterback of the Pittsburgh Steelers and TV personality, as well as Liv Tyler and other celebrities found stimulants to be enormously, almost miraculously helpful. Not unlike Freud, Robert Lewis Stevenson, Ibsen and Thomas Edison, I don’t doubt the result of using the drugs must have seemed amazing. But whether that was proof that they have a disease is a whole different story.
Like the pied piper, where celebrities go, others are sure to follow, numerous upstanding and not so upstanding citizens found the cure. Exactly like cocaine a century ago, the numbers have multiplied, all perfectly legal and above board. Nevertheless, sensitive to the horrors created by doctors prescribing far too much Oxycontin, and the lawsuit pinning the whole disaster on Purdue Pharmaceutical, CVS recently disallowed prescriptions being written for a vast number of people who had had a phone session with companies with a wide reach Cerebral and Done Health practitioners.
It is easy to see now where Adult ADHD might lead, but at the time, Dr. Biederman’s pitch was powerful. Coming from royalty, Harvard and Mass General, those who presumably have the most and best knowledge available, who were we, busy practitioners, to question the certainty of their knowledge about ADHD? I, of course, habitual skeptic that I am, didn’t buy it.
As it turned out there was good reason for my skepticism. Biederman’s income from drug companies wasn’t small. He had received research support from Shire, Lilly, Wyeth, Pfizer, Cephlon, Janssen, and Noven. He is on the speaker’s bureau for GlaxoSmithKline, Lilly, Pfizer, Wyeth, Shire, Alza, and Cephalon. He is also on the advisory board for Lilly, Celltech and Shire, Noven and Alza/McNeil. The key fact against him? Dr. Biederman failed to report to Harvard that he had received 1.6 million dollars from drug company work. (It is reasonable to assume the amount of money he has received is far higher.) But an investigating congressional committee focused on the unreported 1.6 million.
Dr. Biederman is by no means alone. The former editor of the New England Journal of Medicine (NEJM), Marcia Angell, wrote an editorial entitled. “Is Academic Medicine for Sale?” (Angell, 2000). She followed this with an impassioned book, “The Truth About the Drug Companies: How They Deceive Us and What to Do About It (Angell, 2004). The editor of the British equivalent of the New England Journal, the Lancet, wrote in the New York Review of Books, “Journals have devolved into information laundering operations for the pharmaceutical industry” (Horton, 2004). It isn’t just drug companies that are problematic In the Congressional investigation of the ethical issues involved with experts like Biederman it was revealed that the federal grants received in 2005 by Drs. Biederman and his colleagues, administered by Massachusetts General Hospital, was $287 million.
I will not claim that Dr. Biederman and these noteworthy institutions in the ADHD business are part of a conspiracy. But certainly, their common interests highlight how hard it is to walk away from a gravy train. As good businessmen I’m sure they have learned to not look a gift horse in the mouth, something scientists habitually do.
The Basic Nature of Psychiatry’s Failure as a Scientific Pursuit
While this article has so far focused on historical parallels and the sleazy practices of certain individuals and institutions, there are fundamental flaws in the current paradigms that are open to questions of simple logic. They have not been addressed. Let us start with the diagnostic system. The committees that defined individual diagnoses were determined to be scrupulously honest. They wanted the clusters of symptoms that they used to define an illness to be easily observable to everyone and anyone. No controversial ideas about an illness, no contrasting theories about what an illness is and isn’t. Just what could be directly observed. They stated that their conclusions could only be tentative. In line with that they decided they would only use the term disorder instead of diagnosis. The reason for this was that a true scientific understanding of the disorders they were agreeing on was lacking. No one knew at the time (and still don’t know) what the cause was of a single one of the disorders they were classifying. Nor was there a clue about the pathogenesis. They would have to agree on what to call the cluster of symptoms that they determined were relevant to each disorder.
I have no problem with that. Their spirit was the right one, acknowledging that this was the best they could do with the limited knowledge we have. Based on agreed upon observations, it had what seemed to be an objective, a “scientific” skeleton that they believed would loan scientific legitimacy to the uses they had in mind for it.
That was a wrong assumption.
Consider the very different clusters of symptoms that characterize strep throat, meningococcal meningitis, syphilis, gonorrhea, pneumococcal pneumonia. They don’t resemble each other in any way. All can be treated with the same thing, penicillin. How is that possible? Simple. In this case we understand the etiology of these illnesses. They are all caused by bacteria so penicillin is the cure. That is what good science facilitates. Logical thinking based on real knowledge. Would our understanding be furthered if we focused on the enormous variety of symptom clusters and tried to do something based on that. Obviously, the study would go nowhere. It would make no sense at all to treat this assortment of clustered symptoms with the same agent. Or to think there was a fundamental relationship between them. But lacking the needed knowledge focusing on clusters is done all the time in psychiatry.
The madness we see in tertiary syphilis is almost identical to the symptoms we see in schizophrenia. The diseases are not related. Moreover, for all we know, what we are now calling schizophrenia could be many different illnesses caused by many different factors but with the same cluster of symptoms as the final common pathway. And so it goes with autism, and a host of other disorders, including perhaps ADHD. Although I categorically reject that it is biologically based for the huge number of patients diagnosed with it, I don’t doubt a small number might have what used to be called, minimal brain dysfunction, undetectable neurological defects that also effects concentration.
It’s no one’s fault that we don’t have better answers to this and the many other illnesses that we remain in the dark about. But fact is fact. We don’t have the information we need. Nor are there many discoveries that might lead us to new and important ideas. Again, it’s no one’s fault. We are where we are.
Actual scientists in neuropsychiatry live in a different world. They are biochemists, and biologists, physiologists and neuroanatomists, a whole assortment of specialists who work in labs. They understand how little we know, which if anything motivates them to keep doing what they do, scratching at the work still to be done. They have little interest in psychiatric diagnoses or other issues that clinicians think are important. The attempt to be objective, that part of the spirit of the DSM writers is familiar to them. It is the rest of what goes on in psychiatry that is foreign.
That doesn’t mean there aren’t many “clinical” neurobiologists similarly hyping the cutting edge of discoveries being made in their field. There have been some neat discoveries. In lab animals they have been able to study and create conditions where neurons regenerate and rewire. And everyone’s favorite, our ability to get pictures of the brain revealed that the hippocampus, the center of memory storage, is much larger in London taxi drivers than it is in the rest of us. But the practical applications of current knowledge is far off in the future and provides no justification for best selling books claiming that because of modern technology the authors can rewire their readers’ brains.
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But back to the task on hand, psychiatry, the claim of psychiatrists that what they do is scientific and the widespread belief among the public that this is the case. That is the reason for this article. My problem is in the use being made of DSM descriptions, the false claim that evidence-based medicine is scientifically sound, and the implication that non-evidence based approaches are ruled by wild conjecture. That makes my work illegitimate instead of sensible.
How does evidence-based medicine present itself as scientifically valid? They compare the results of a medicine (or cognitive behavioral therapy) with placebo on a given diagnosis and if the treatment does better than placebo it is said to be evidence-based. What is impressive is that they use real numbers, exact numbers, statistics to reach their conclusions. In the vast unknowable universe, the unsettling cavern of our ignorance, nothing is as reassuring as the certainty of numbers. It is not opinion being weighed. It is numbers. The judgement of practitioners isn’t needed. Treatment protocols are explicit. The numbers make clear what should be done. Psychiatrists are told exactly what the evidence indicates.
The first thing to be challenged is the trust placed in statistics. It is not just psychiatry. Jeremy Z. Miller’s book The Tyranny of Metrics addresses this issue: “In recent decades, what I call “metric fixation” has engulfed an ever-widening range of institutions: businesses, government, health care, K-12 education, colleges and universities, and nonprofit organizations. It comes with its own vocabulary and master terms. It affects the way that people talk and think about the world and how they act in it. And it is often profoundly wrongheaded and counterproductive. Metric fixation consists of a set of interconnected beliefs. The first is that it is possible and desirable to replace judgment with numerical indicators of comparative performance based on standardized data. The second is that making such metrics public (transparency) assures that institutions are actually carrying out their purposes(accountability)…But not everything that is important is measurable, and much that is measurable is unimportant. Most organizations have multiple purposes, and that which is measured and rewarded tends to become the focus of attention, at the expense of other essential goals.” Albert Einstein also warned against the same trap “Not everything we count, counts; not everything that counts can be counted.”
Evidence-based medicine is particularly guilty of this overvaluation of numbers. When we consider the fundamental assumptions, with a little bit of thought the reasoning borders on absurdity. One can do precise measurement of results but as we have seen, the original diagnosis used in that calculation is, at best, an approximation of an illness. So the numbers, even though carefully tabulated, while not being worthless, the most they can provide is an approximate strategy. Yet it is slavishly obeyed as an absolute, a scientific approach and answer.
There are better reasons for questioning blind usage of it. Let us use an example from medicine where, unlike psychiatry, we have a clear understanding of what is happening. Suppose a patient had congestive heart failure (CHF) due to hypothyroidism. Supplying thyroid hormone would cure his CHF. Despite this fantastic outcome, in a larger group of those with CHF the treatment would fail miserably as an evidence-based treatment for CHF. Yet it is exactly the right treatment for this particular patient’s CHF. Our knowledge about what is going on makes that very clear.
Suppose we didn’t have that knowledge. No one knew about the thyroid’s effect on the heart. That is our situation in psychiatry. If there was a report that a miracle had occurred using thyroid hormone it would be ignored, if the issue was in psychiatry because statistics involving the larger group would show it was unsuccessful as an evidence based treatment for CHF, there would be little curiosity about it. Psychiatry faces that kind of inadequate knowledge all the time. But is content to stick with their paradigm.
In the name of science, there are very few if any presentations of individual case histories in the psychiatric literature. Evidence based cures are all that matter, statistics involving groups of patients with the defined cluster. In psychiatry, successful treatment of an individual as opposed to a group would be dismissed as anecdotal, a pejorative term in the literature which prides itself on being scientific. The interest is on effects on a population of patients with a given diagnosis. Not on individual cases. Later, I will describe some of my patients that were treated with what I believe was a sensible strategy, but which would be dismissed as unacceptable because what was done was not based on scientific psychiatry. But first let us address a different strategy practiced in psychiatry, one that was used before we had evidence-based medicine, expert consensus protocols.
As we saw during the Covid 19 crises, when we knew practically nothing about the epidemic, the term “expert” was used over and over until it became laughable. “Expert” opinion is somewhat like the Wizard of Oz. Lost in a world that she couldn’t comprehend, Dorothy had to turn to the wizard, first in her imagination and then as a realistic strategy. She followed the yellow brick road. When something is known and understood there is no need of experts. The information is simply there. When we don’t have the knowledge to answer our questions, but when it is crucial to have those answers, we turn to “experts”. It should be noted that academicians like Dr. Biederman invariably were presented as experts. The long list of qualifications presented by him is the kind of overkill in marketing that we expect from wizards.
In psychiatry, worse than evidence based medicine, the creation of “expert consensus protocols” was and is a stain on the profession. Yes, I want to hear smart people take their best shot at a guess. However, for many practitioners the protocols, like evidence-based medicine, turns the clinician’s decision making away from his best judgment into being compliant with authority. In our crazy world of lawsuits, those not following expert opinion are on thin ice. So, clinicians may feel they have no choice. Besides that, given the unpleasantness of cognitive dissonance they may even believe they share the authority of the experts, feel sure that what they are doing is absolutely the best treatment that can be offered, one recommended by experts. It doesn’t matter if they understand the patient in any depth. Few psychiatrist attempt to understand their patient’s problems that way. How could they do otherwise, seeing the patient once a month for 15 minutes? They needn’t be bothered by the complexity of the person appearing in their office. They have the patient’s disease neatly spelled out by the agreed upon diagnosis cluster. All they have to do during a visit is find out if each of the cluster of symptoms characterizing the diagnosis are worse or better, and also ask about side effects. The rest of what is going on with the patient is irrelevant, just as it matters little for an orthopedist treating a sprained ankle to ask about patients’ relationship with their spouse or children or how they are doing at work. How they are spending their time is off the point of the visit. They have the patient’s disease neatly spelled out by the agreed upon diagnostic criteria of experts, the agreed upon expert treatment protocol and they just have to reach for their prescription pad to be glatt kosher. The key point is clinicians have been blinded to all kinds of interesting information. Productive thoughts and observations have been narrowed to a single perspective.
In the world of experts, non-believers are treated as deniers of science, as heretics. Ironically, like the wizard, science is often waved as a banner. Its virtues can act as a smokescreen. The language, the prestige, the trappings of science can be so distracting that science’s core value is overshadowed, absolute clarity about what is known and not known. The vast extent of what we don’t understand is rarely acknowledged to the public. It isn’t intentional lying. Most psychiatrists believe we know more than we do. One of the reasons clinicians turn to authority rather than try to think out the complicated issues of each patient is that psychiatrists are like most people. Authority is comforting, a lot more satisfying than the uncertainties we often have when we must think for ourselves. Having the right treatment course clearly defined helps a lot. I am not unsympathetic to the current practitioner’s motivation. Particularly, as I noted, in today’s atmosphere of malpractice lawsuits. Imagine being accused of not following the science or the experts when something has gone wrong. There really is little choice. But whether that often enough leads to the right treatment outcome or new treatment strategies is a wholly different question.
Not uncommonly a validated treatment doesn’t work. Okay, the treatment is not expected to work 100% of the time so a different approved treatment is tried also using the evidence-based protocol. And if that doesn’t work with several tries, an entirely new strategy is available. Some clinicians, when they have exhausted the various protocols dictated by the patient’s symptoms decide their patient has a different diagnosis. The medicines aren’t working because he or she has an atypical case of what is now the new diagnosis. With this in mind they then follow a different protocol for that diagnosis that is evidence based. Over years of treatment this can happen several times so that treatment begins to resemble throwing darts at a board. This is not rare. Articles are now being written in the popular press about patients who have been assigned with five or six different diagnosis and with different, new treatments tried again and again. It is egg on the face of psychiatry. And not surprising at all. What is interesting is that instead of owning up to our insufficient knowledge, most clinicians retain their confidence in the omniscience of our scientific authorities and believe we have the knowledge that is needed. What matters is that the practitioner may take pride that he is keeping up with the latest and greatest recommendation of the experts, which reaffirms he is a board certified professional. If he isn’t dedicated to the “science” he becomes uncomfortable charging huge doctor fees. Using words like “maybe” or “we don’t know” is not the best marketing tool for the public and is unlikely to add to the clinicians confidence that he is serving up the very best
Allow me to present a few of my former cases with treatment strategies that are totally unacceptable to those demanding evidence-based treatment. But first I need to present a different way of looking at drugs. I explained the effectiveness of stimulants for ADHD by describing how it effects the psychology of individuals, makes drudgery no longer be drudgery, even fun. The same can be done for other drugs. Although I came to this conclusion independently, Herman Van Pragg advanced it ten years before I saw things his way. Van Praag argued that pharmacological agents can be viewed as inducing particular psychological states which, though not specifically related to diagnosis, are nonetheless the basis for the usefulness of the medication.
SSRIs, and bupropion are believed to be roughly equal in their antidepressant efficacy. But while each stimulates neurotransmitters to give a positive ring to the day, they do not induce the same psychological profile, since rather than effecting serotonin, bupropion acts primarily by enhancing dopamine, and to some extent, norepinephrine. I call it a “kick ass drug”. It tends to be activating rather than calming. Most clinicians use bupropion in depression when anergia (low energy) or anhedonia (an inability to experience pleasure) is prominent. They tend to avoid it if anxiety or agitation characterize a depression. Not surprisingly, it is one of the few antidepressants that hasn’t proven effective with panic disorder. It can give an edgy feeling, which, in an already nervous person, can set off new panic attacks. But here is the important point. There are no hard and fast rules. There are as many exceptions as rules. Guidelines based on the general can serve as starting points but eventually the particulars are more important, especially when all is not going as planned. Here is an example.
When Mr. K., a 50-year-old salesman transferred to my care, he was already on Wellbutrin (bupropion) for panic disorder. Since this didn’t make sense for that diagnosis I took him off it. After about a month his condition worsened so he was put back on it and he did well. It took several months in weekly psychotherapy sessions before I came up with a plausible explanation. It wasn’t that his brain chemistry was different than others so that bupropion effected his brain chemicals differently (a speculation that a chemotherapy-oriented psychiatrist might assume). I thought it more likely, after I got to know him better, that bupropion helped his panic attacks for reasons particular to his story.
As noted Wellbutrin seems to bring energy, initiative, clear mindedness, and increased ability to experience pleasure, even when working at a job. It has qualities that are associated with stimulants and cocaine. Like them it primarily effects dopamine, but unlike abusable meds, its effect is seen over the course of several weeks, not immediately after taking a pill. In this patient’s case, I eventually learned that his panic attacks were related to his tendency to procrastinate. He was a salesman who made too many promises and failed to deliver in good part because he hadn’t done necessary paperwork. The work that needed to be done hung over him constantly making him nervous. Each day the possibility that the “s-t” was about to hit the fan jolted his consciousness. Judgment day was near. Interestingly, Mr. K had read about anxiety and panic attacks being biological, as having no meaning, fear and panic without a cause. He had never connected his symptoms to anything he was doing, or thinking, never connected it to his psychology at all.
Fortunately, he and I got along well. He trusted me like a good friend, which in this case I was (breaking another taboo). Together we learned that bupropion seemed to put him in a mode where work that he customarily slacked off on, became easy, half challenging, sometimes stimulating and interesting. This is not surprising since, as we saw with cocaine and amphetamines this seems to be a general characteristic of dopaminergic medicines. In any case, as a salesman he was forever making promises for delivery that he didn’t keep because of his failure to do the paperwork. He kept up with his work far better when he was on Wellbutrin than when he was off of it. Hence there were fewer feelings of impending doom on the meds, less anxiety and no panic attacks.
In terms of statistics, Wellbutrin was not an evidence-based medicine for panic attacks. Beyond that it didn’t really make sense to me either since it could make some patients jittery and hyped up. I would have never chosen it, but the fact is that for this patient it was exactly the right medicine. I would not have had a clue about what was going on if I only saw him once a month for 15 minutes. In therapy he was acknowledging a behavioral pattern that was certain to bring him trouble. While he was in treatment with me he overcame this pattern, but I don’t know whether this change would be lasting. (It is hard to make lasting changes at the age of 50.) I was later to learn that although he wasn’t a full blown ADHD person, he had very real and deep reasons to not do what is expected. He had a very mean moralistic stepfather. They often hated each other.
It would take us far afield to describe this aspect of his case further. More to the point the uniqueness of his treatment was of no interest to the journals. The opposite. Anything reported about this patient’s conflicts would be dismissed as anecdotal, the story of one person, not worthy of attention because it could not be part of the statistics that define the truth.
The second case is similar. A patient with post-traumatic stress disorder (PTSD) for over ten years presented on high doses of Adderall that had been given to him for what his family physician diagnosed as adult ADHD. (He had reported difficulty concentrating.) His physician then became uncomfortable administering stimulants and sent him to me. It was soon apparent that he did not have ADHD. But he reported that on the Adderall his post-traumatic stress disorder was the best it had been in over a decade. It took a while to make sense of this but once again the explanation appeared to be found in his experience. He and his fiancé had been trainees at a state police academy. His fiancé took her gun and blew her brains out. My patient found her body. He couldn’t clear his mind of the scene. During the day, during his dreams, her brain and skull fragments on the wall remained vivid images grabbing his attention. It could happen anytime. To make matters worse, he became a paramedic working on an ambulance which brought him to car crash scenes where horribly damaged bodies were not infrequent. Eventually in therapy 5 years before, he realized this kind of work was not good for him, and in more recent years he had worked on a hospital ward. Even with SSRIs and benzodiazepines, his PTSD not infrequently took control of his mind. This no longer happened with the addition of Adderall given by his family doctor.
As I got to know him my guess was the Adderall brought back his pre-morbid, state trooper defensive structure. Instead of experiencing his trauma again and again as a helpless passive victim, the essence of the psychological position occupied by those suffering from PTSD, on the Adderall he had returned to being a take charge kind of guy. Coincidentally I was also seeing another patient with PTSD. She was a drug saleswoman who had been a work out fanatic. She spoke in short staccato sentences. boom boom, bam bam, not a trace of sentimentality in her, not a soft syllable in her repertoire. She had been in a car accident and broken her collarbone, right arm and one of her legs. She couldn’t work out. She kept re-experiencing her helplessness in the accident. She was on SSRIs which were helpful but not curative. The addition of Adderall worked like a charm.
Like the other example, this is not an endorsement of Adderall for PTSD generally. It would probably fail in a population of patients with that diagnosis. It is an endorsement for this kind of thinking in formulating cases where this might be helpful. We are not talking about psychoanalytic understanding being necessary, but it does require training to think psychologically in a productive way.
Finally, a case where the medication selected is within evidence medicine’s parameters, but the reasoning I used for numerous medication decisions was totally unlike the kind of care administered by 15 minute once a month psychopharmacology. First, a conjecture about how SSRIs affect individuals and why they are so clinically useful for so many psychiatric conditions. A case can be made that SSRIs are efficacious in conditions as disparate as borderline character, depression, obsessive compulsive disorder, anorexia nervosa, panic disorder, social phobias, and so forth because increasing serotonin has a psychological impact that is nonspecific to the disorders in question. Alcohol will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis. Analogously, SSRIs typically impact individuals in ways that are not specific to diagnosis. What is that effect?
The most frequent description of the effects of SSRIs that I have heard from my patients was “It doesn’t matter.” or “Don’t sweat the small stuff.” or “What’s the big deal?” This quality is irrelevant to a clinician focused on whether the patient’s symptoms are better or worse. Emotional indifference has even been described as a side effect. But for the most part while it is hardly noticeable to the clinicians and hasn’t struck anyone as worth mentioning the public has noticed. Here is a T shirt that soon hit the street .
I am arguing that it is this “Don’t sweat the small stuff” perspective that is SSRIs powerful blessing, and hopefully, not too often, its curse. It means relief from worry, relief from the feeling that something is missing, something needs to be done, something needs to be fixed, “my makeup isn’t right, the sky is falling, I won’t be able to pay my bills, I’m not smart enough, I won’t be able to tolerate the loneliness if I leave my lover” (even if he/she is abusive).
Regardless of the particular worry, SSRIs supply, if not always happiness, a nice contented feeling that all is well and will be well. That can allow parents to be able to play with their children more, fret less over the details, appreciate what is, actually want to do the proverbial modern mantra, stop and smell the roses. They are the answer to existential angst. Perhaps Sisyphus, if he had only been born in the 90’s, could have left that rock alone and had a nice snooze.
On the other side of the equation, I had a psychiatrist colleague who took Prozac to relax and enjoy his vacation. It worked very well. He told me that he tried it at home when he returned. He quickly stopped it when he found himself thinking, “Who cares?” when his patients described their problems. According to explanations given to me, SSRIs are not popular in Japan or in the United States among engineers who are precisely designing a bridge.
According to this theory it is the “well whatever” feeling, emotional blunting, that has made it so useful in a great variety of different syndromes. It was originally FDA approved for depression But I found it useful in a variety of DSM syndromes. Thus, for a person with anorexia nervosa to react with “well whatever” after they have gained a pound or two is to get at the heart of the problem. The same can be said for body dysmorphic disorder, a condition in which a person’s life is completely distorted by imagined or slight body defects (such as thinning hair, a big nose, and the like). In obsessive-compulsive disorder the ability to treat compulsions and obsessional thoughts in this manner is a godsend. Similarly, a depressed person’s preoccupation with the hopelessness of their situation, the gravity of their errors and defects, the inadequacy of their decisions, and so forth will be enormously relieved to regain a less “negative” perspective. In panic disorder, a condition often characterized by exquisite sensitivity to body sensations, and a catastrophizing of consequences, (I once had a patient who described a horrible attack of panic because she feared something was going wrong with her vision. Only later, when she removed her glasses did she realize that her dirty eyeglasses had set her off) SSRIs have been found to be effective because the sense of catastrophe leaves. For similar reasons social phobias and bridge phobias and flying phobias often become manageable on SSRIs, as does intermittent explosive disorder which may improve because it is harder to press the patient’s button. Alcoholism, pathological gambling, overeating and the like may respond if a sense of frustration has significantly contributed to the pathological behavior. (They may worsen these conditions if a heroic disciplined battle is being waged against temptation, which is then weakened by a “well whatever” letting down of the guard.) SSRIs can help perfectionists (“obsessive compulsive personalities”) give themselves a little (or a lot of) slack. They can allow borderline personality disorder patients to cool their heels, to not be tortured, like a wounded lover, when the person, upon whom they have passionately centered their survival, is not reciprocally involved with them. And so, we can apply this perspective about SSRIs down a long list of DSM defined disorders that have been empirically found to be treatable by a change in brain chemistry.
This perspective also suggests itself as useful in psychological circumstances where a specific diagnosis is not at issue. Thus, for instance, a not uncommon treatment scenario is teenagers who are having a very rough go of it with their classmates, kids who are picked on precisely because of their vulnerability. The popular students are the ones who are cool; that is, they don’t blush easily, are bold with the opposite sex, and so forth. Adolescents often turn to illicit drugs (analogous to adults at cocktail parties), to get rid of their social anxiety. But teenagers are often more savage than adults, meaning they out and out torture the nerds. It is not unusual for adolescents to come to therapy because they feel like misfits and to put it bluntly, the use of SSRIs may be very helpful here to magically assist them in having a thicker skin, which is exactly the quality they needed all along to not get picked on and possibly even have the “cool” to be “popular.” It should be noted that using a medication to help them does not require conjuring up a phony “diagnosis.”
Here are two cases illustrating the use of SSRIs:
Mrs. D a very attractive computer consultant at IBM with a terrible foster home past was successfully treated for depression with Prozac. She had never felt she was as good as a techie as her 5 male partners. She had a never-ending need for reassurance, which was embarrassing to her. Every night on her drive home she tortured herself with the things she felt she had mishandled. Her beauty made it easy for her to turn to a series of lovers unsuccessfully hoping to find confirmation. On Prozac all of this changed. She acknowledged that she wasn’t as good a techie as her partners, but she wasn’t bad. More importantly, she realized she was indispensable to her team. She was the only one with sufficient social skills to handle their clients. For the first time in her life she was able to ask questions at conferences without feeling like an idiot. No longer hungry for confirmation she was also able to stop her cycle of love affairs which had led nowhere. On the other hand, her comments coming off meds was noteworthy. “I feel like I’ve been drugged for two years. Now I want to take a look at my checkbook.” She also reported behavior that now, off the meds, seemed bizarre. She had bought a puppy that she kept in an unfinished basement. While medicated she had not cleaned up the poop, reacting with “well whatever”.
Mrs. L. had originally required 40 mg of Paxil (an SSRI) to recover from a postpartum depression. After 12 months on the meds, an incident happened which disturbed her. She was visiting her one year old at his daycare center during her lunchtime when one of the workers began screaming at another infant without picking her up. The next day Mrs. L went shopping during her lunch break. Later that week a coworker became tearful during the course of a conversation with Mrs. L. regarding her own child’s daycare center. Only then did Mrs. L. wonder about her decision to go shopping the day after she had witnessed the daycare worker’s inappropriate reaction. She wondered if her Paxil had made her indifferent when ordinarily she would have reacted and worried about such a thing.
We decided to taper the dose of medicine to 20 mg. Sure enough on less medicine there was a dramatic change in her perspective about many things. For the first time I learned about the pressures she had been under at the time of her original hospitalization. Mrs. L. had tried to find time to be the powerhouse worker at her job that had brought her so many promotions in the past, an ideal mother for her newborn infant and responsive to her husband’s very exacting standards about her housekeeping. Suddenly, without the higher doses of Paxil her fury poured out. She described, in detail, episode after episode in which her husband stood to the side and supplied her with a never-ending critique of her adequacy as a mother. The higher doses of medication had muted her responsiveness, allowed his criticism to go in one ear and out the other, but now there would have to be change “or else”. Mrs. L. also acknowledged that she had not been doing her job as carefully as in the past and eventually the company would discover her drug induced “what the hell” attitude. At home, she had bounced several checks, something that had never happened before she was on medication.
Therapy now turned to how her life would have to change. She seriously considered stopping her job. She loved being a mother and didn’t want to miss out on her son’s crucial early years. She demanded changes in her husband (with the threat of divorce). Her new assertiveness had rapidly put him on good behavior even before marriage counseling started. A few times during her sessions she became tearful about her dilemmas. Although we discussed the possibility of returning to higher doses of medication should the need arise, she was not eager to do this. She felt her tears were about real things and did not consider herself depressed. She did not feel hopeless nor helpless. Her sleep was not as restful. She sometimes tossed and turned. But she was okay. We joked that we might go up on the Paxil temporarily if and when she needed a vacation from her stresses. In fact, throughout I was concerned that her greater emotionality might be a prelude to the return of her original symptoms. But our perspective was quite different than an automatic increase of medicine at the first sign of tears. As it happens she did not need to return to higher doses. She did quite well, eventually deciding to work part time.
Three months after making that decision she was the happiest she had been in years.
It is noteworthy that when she was reduced to 10mg (at her urging) there was another improvement (depending on perspective). She again noticed dust on her furniture. She noticed that the pictures on her table had been placed haphazardly. She arranged them more aesthetically. She did not feel driven to take better care by the internalized monster described in obsessives by Shapiro in Neurotic Styles, by an unending “I should, I should I should.” She took pride in her newly regained “attention to detail.” She also regained a degree of empathy for her husband. There certainly was the danger that she was returning to a dynamic of taking care of everyone and everything, of offending no one, a role that she had assigned herself from early on in childhood. This pattern may have played a part in her original postpartum depression as she tried to juggle her responsibilities and became overwhelmed, consequently generating forbidden anger at her newborn. Certainly, her regained empathy for her husband might be the beginning of permission for him to begin carping again but she thought she “would be able to handle that.”
What are the lessons to learn from these case histories? At the very least, psychiatrists should know their patients reasonably well if they are to prescribe medications wisely. This is true whether or not it will eventually be determined that the odds of a patient developing a disorder has been increased by biological factors. Prozac and the other SSRIs are too powerful, too far reaching in their effects, their influence too subtle in too many areas of a patient’s life, to be given by gynecologists, family practitioners, physicians assistants, and others who have brief contact with their patients. They are too powerful to be given by psychiatrists who see their patient for 15-minute med checks once a month and know close to nothing about their patient’s lives.
The treatments I have described will not prove efficacy to a scientist’s satisfaction. Moreover, some, or all of my formulations may turn out to have been wrong. But it throws down a challenge. These ideas are only a fraction of what might be possible if others were thinking this way. That should be encouraged. Psychiatric journals should be publishing ideas on subjects like these, case histories so that we can discuss and brainstorm, and end the monopoly that “scientific” psychiatry has imposed on legitimate practice and discussion. Our “experts” should weigh in on these issues. Hopefully, one day our patients will be effectively treated by a psychiatry entirely based on science. However, we are decades, perhaps centuries away from being there. Until we have the knowledge to practice using scientific discoveries, we are doing a disservice by making believe we scientifically know what we do not, and ignore faculties we possess, or that lively discussion and training can improve. It might be helpful to our patients.
Fine, the profession wants to call what they do scientific. But when our scientific knowledge is as thin as it is, rigidly adhering to that model is interfering with thinking more flexibly and effectively. It isn’t possible with training programs not training future psychiatrists to think about their patients in a psychological context and it is not possible to do this with once a month short med visits. This is not a call for a return to Freud but it is a rejection of the myth that everything reduces to science and biology. Yes, what I am advocating is not scientifically verifiable but it is realizing that the scientific understanding, particularly what is being claimed to be scientific knowledge is completely inadequate. I would call it phony, particularly when it interferes with sensible judgements and speculations that psychiatrists can and should share trying to make sense of their cases. We desperately need the kind of journal I am describing, one that contains an abundance of anecdotal thinking, case histories describing individuals and ideas, even speculations, about treatment decisions. It is the only way to return to the discussion needed by psychiatry to lift itself out of its untruthful public and private posture, to hopefully avoid the moribund state it is moving towards. Business may be booming but more and more, the public is awakening to how sterile the field is. There have been recent articles exposing the myth of chemical imbalances. I wrote about that twenty years ago. It took no brilliance for me to come to that conclusion. Few people who addressed that issue back then agreed with the myth of chemical imbalances. But there was a strange silence about it. The need of the profession to appear on the cutting edge of neurobiology outweighed scientific modesty. While many of today’s critics want to blame Big Pharma for the scandal, we are far from innocent. Psychiatry is not emerging in public awareness with a flattering image. Deserved or not, perhaps it explains why so many people avoid psychiatrists, and discover herbs and Yoga to comfort their troubled souls.
Once again, I might be wrong in the specifics of how I formulated the cases I used for illustration, but meaningful discussion about that can only take place if there is agreement that psychiatric science is not there yet, not even close to being there. We need debate, a lot of it, more questions, less answers. In psychiatry, considering how much we still don’t understand, our steps forward should be exploratory, investigative, not closed off by the chilling effects of authority. Meaning “science” should not become an authority. It is the very essence of what science is not. Real scientists operate in an environment of doubt. They continually challenge the given and try to prove their version of the truth will prevail. Only by tearing down and reconstructing knowledge with adequate proof do we move forward.
The temptation to come up with fake conclusions is always strong. There is no shame in saying “I don’t know” especially when no one knows. Perhaps that is not the way to hold on to patients willing to pay high fees for “experts” in psychopharmacology and it is understandable that many would rather deliver to their patients the certainties authorities have given them. It is corrupt but hey, all those years in medical school and residency training deserve a rich reward. We are all waiting for the day when we have scientifically answered the important mysteries confounding our field today, but until then it is dishonest to act as if that day has arrived.
Science, Pharmaceuticals, The Quest for Profits, and My Gratitude to Drug Companies
Lastly, I am not happy pointing out the sleazy aspects of drug companies. I owe my life to them. I am 79. My mother lived to 99. Lipitor ended a consistent streak in our family. Beloved Nature has blessed my whole family with very high cholesterol. My mother’s father was dead at 59, a heart attack on the subway. There were others before him. How many millions of people are alive like us, rescued by statins? Not just statins. There should be a ticker tape parade on Broadway for the scientists at Pfizer and Moderna who developed the Covid vaccines. Millions are alive because of their work in the labs.
I discovered something strange about this topic. I thought the polarization in our society was mostly about political subjects, that there was far less black and white thinking in other areas. I sent a similar article to this one to a group of people who had written recent articles about the myth of chemical imbalances. Their criticism was blistering but fair enough. However, they went wild when they read I credited drug companies with saving my life. As with other hot topics, the polarizations that characterize our era are too explosive to be handled by exploring the grey. That didn’t capture what they feel is true. They apparently believe societies consist of villains and angels, like the old cowboy movies, the good guys dressed in white the bad guys in black. Nothing good can be said about the guys in black. Their vehemence surprised me.
I agree that in search of profits drug companies’ marketing department told a lot of fibs, accentuated the positive, downplayed the negative but I don’t know any industry where that isn’t done. Okay it is more serious when health is involved. More than that, the corrupt people in various drug companies were able to corrupt far too many corrupt academicians. It is a multibillion industry. They are willing to pay a lot of money to get willing professors to think the way they want them to think. But frankly, I rarely paid attention to promotional material and lectures coming from drug companies. I was more than willing to eat their donuts at work, receive their free pens, and go to expensive restaurants, and even to a free afternoon ski trip on a bus with all the other psychiatrists in my area in exchange for us listening to their sales promotions from professors they had hired. But I always saw it for what it was. I didn’t understand why so many of my colleagues were taken in by those talks but that is another topic. Nevertheless, in the strange ways of the real world, the focus on profits by businessmen running pharmaceutical companies, yielded results. It paid for the researchers in their labs, the true scientists that have brought us so many life saving meds to fight the horrors, the sicknesses that nature throws at us. So yes, give them hell for their evil doings, but kiss their feet for all the lives they have saved, lives that would have been doomed if the drug companies hadn’t made the money to do their scientific research. They may not be Gods. They aren’t able to walk on water, or part the Red Sea but true science has given us miracles.