Saturday, May 25, 2019

Chemical Imbalance As Advertising Meme

After a protracted discussion on the previous post, I thought I would go down to the University of Minnesota Biomed library today and look at the drug ads in psychiatric journals at about the time Prozac came out in 1987. I was interested in the trends before and after so I picked the years 1985 to 1995. I also picked the journals the American Journal of Psychiatry, Archives of General Psychiatry (currently JAMA Psychiatry), and the Journal of Clinical Psychiatry.  I was going to include JAMA and the New England Journal of Medicine.  They had about the same number of ads but none of them in that year contained ads for psychiatric medications.

This kind of search is labor intensive these days. There was a time on the early days of the Internet when entire journals with all of the ads were scanned in. As a subscriber I could have run that search from home.  These days, all of the ads are gone and the references are saved as text files only. In order to see historical ads - the hard copy of the original journal needs to be examined. Even then there are some problems.  I encountered some bound volumes where the ads were physically removed. There were two to three bound volumes per year and additional copies of the NEJM and JAMA - I may have looked at 75 bound volumes over 4 hours.

In many ways it was a walk down memory lane.  Clozaril and Haldol Decanoate ads were especially heavy in the early 1990s.  There were ads for medications that I prescribed all of the time like Navane and Pamelor and ads for drugs that I seldom prescribed like Stelazine, Serzone and Luvox. There were ads for new drugs that I would prescribe once like Paxil.  It was a reminder that despite all of the advertising - a  lot of drugs end up never being prescribed by physicians.  My reason for being there was to look for the origins of the term "chemical imbalance" in this advertising.

I decided to embark on this project because of all of the inaccuracy about the term, especially the tendency to blame psychiatrists for it. In my previous post, I attempted to point out that it is a fairly straightforward process to conclude that the human brain does not run on chemical imbalances - just based on the average scientific knowledge of physicians. On the advertising side, I was there for the first National Depression Screening Day in 1990 and that was the first time I heard the term. The event has been criticized as a venue for allowing a pharmaceutical company to showcase their product.  I participated in the event for 3 years and the advertising involved was much more subtle than is found today at NAMI walks for example. But the question is whether the advertising meme "chemical imbalance" was introduced at that time. Any event that happened 30 years ago is very hard to track. As the Public Affairs Rep for my District Branch of the APA, I had a lot of files about it that I subsequently trashed. I am guessing there were also some files on disk drives that would have been helpful.  This is a reconstruction without that data.

I successfully located the first Prozac ad in AJP from 1988.  The graphics are all iPhone photos so there is some distortion.  Chemistry is emphasized on page one as in the chemical structure, chemically unrelated to other antidepressants, distinctive chemistry, and the first highly specific and highly potent blocker of serotonin reuptake.

Why is this important? At the time most of the antidepressants being used were tricyclic antidepressants.  They could not claim any specificity and in subsequent ads manufacturers start to compare possible side effects based on transporter monoamine protein and receptor affinities. The Prozac molecule was being hyped as being chemically unique and with a better side effect profile. As Prozac started to sell more it became a blockbuster drug for Eli Lilly and at that point the manufacturers of other new antidepressants noted and the competition heated up.  There were some direct references to Prozac in the ads from competitors.

The best example is this Wellbutrin ad from AJP in 1991. Prozac is directly mentioned in the ad and reasons are given for choosing Wellbutrin over Prozac.  Being non-serotonergic is one of them and this is more of a counter to Prozac advertising as being a unique first highly selective serotonergic drug.  It gives little or no weight gain as a reason, but at the time I was seeing obese patients who were taking 80 mg of Prozac because their primary care physicians told them they could lose weight taking it. Of the other bullet points it seems that lack of sexual dysfunction would be  the most relevant. The marketing decision in this case was a conscious decision to go after the purported serotonergic effects of Prozac rather discuss the hypothetical mechanism of Wellbutrin.  The side effect of Wellbutrin that most physicians are concerned about - seizures - is in the smaller print below the bullet points.

Effexor came up with similar ads.  In the late 1980s and early 1990s, synaptosome technology was invented to look at binding affinities of central nervous system medications to specific receptor sites.  The quantitative aspects of these studies were generally globalized in the psychiatric literature to qualitative ballpark effects.  For example a plus or minus grading system could be used ranging from no effect at a receptor (-) to a robust effect (++++).  Effexor advertising used this to compare side effect profiles among the competitive antidepressants at the time.

This ad emphasizes that Effexor is "a structurally novel antidepressant and is chemically unrelated to any other available antidepressant."  It shows the table with comparisons to tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) and what might be predicted based on the in vitro synaptosome data with the qualifier that the clinical significance of that data is unknown.  Clinically most people are able to tolerate all three classes of medication but some will not.  The differences can't be predicted on the basis of the receptor binding studies because of receptor heterogeneity and differences in drug metabolism.  For example, I still prescribe TCAs. It is nortriptyline and it is the only one I have ever prescribed. At the doses I prescribe and per the table in the ad - it is as well tolerated as SSRIs and SNRIs (Effexor).  The ad appeared in the AJP in April of 1994.  On that basis the argument could be made that it is an appeal to the technical expertise of psychiatrists and it should contain this information.  That also points to a weakness in my informal advertising study and that is a lack of ads from the non-technical consumer literature from the same period. (see supplementary on a proposal).

I have 30 additional ads from the journals but the themes are roughly the same. An emphasis on medicinal chemistry and the suggestions that some chemistry is better than others. Interestingly, in my previous post the whole point was that this is the kind of argument that would not fly based on what the average physician knows about chemistry and molecular biology. Psychiatrists should know a lot more because the evidence for and against these theories had been reviewed in the psychiatric literature 20 years before these ads came out (1974-2002) (1).  And they are engaged in clinical practice and need to be skeptical of newly introduced products and claims.

What I did find so far is unequivocal evidence that the chemical imbalance meme was used to directly market antidepressants to the public.  The Zoloft ad embedded at the top of this page from 2001 is the first example.  The second example is this Paxil ad from the same year.

That is what I have so far.  See the Supplementary below to find out what you can do to complete the story. I don't have a problem with people telling me that their doctor told them that they have a chemical imbalance and their antidepressant is supposed to treat that. I don't have a problem with people saying that their psychiatrist told them that.  I do have a problem with people saying that all or even most psychiatrists say this and that psychiatrists are behind this meme.

There is an exaggerated focus on the mechanism of action of medications used for psychiatric indications. I have never heard anyone say their doctor told them about the mechanism of action of antibiotics or even their blood pressure medications. In the case of antibiotics it is clear that people demand them and they don't care what the risks or mechanisms are.  This advertising campaign may have something to do with the conversion of folk psychologists to folk psychopharmacologists.  A friend of mine also brought up an important aspect of this campaign that is also addressed by these manufacturers and that is legitimacy. For decades people with depression and anxiety were viewed as weak people with a questionable problem.  My friend told me that these ads confirmed that she had a serious problem that needed a serious solution and that it was finally acceptable to talk about it.  Say whatever you want about Big Pharma advertising but it apparently carried the message that current "Let's Talk About Mental Health" programs do - but over 15 years ago.

The attribution of an advertising meme to psychiatry and psychiatrists despite the fact it has never appeared in 30 years of psychopharmacology texts is not a trivial fact.  The advertising videos posted here  were viewed by tens of millions of people.  I hope to get more information and still have some people to contact. With any luck I will be able to fill in the additional data between the release date of Prozac in 1987 and the ads posted here from 2001.

Please send me anything you might have from those dates.

George Dawson, MD, DFAPA


1.  Nathan KI, Schatzberg AF. Mood disorders. in Review of Psychiatry, vol 13. American Psychiatric Press, Washington DC(1994): p.171-184

Supplementary 1:

From the  information I posted above it is clear that chemical imbalance was an advertising meme introduced during the height of competition of blockbuster  antidepressant drugs.  The  common Wall Street definition of a blockbuster pharmaceutical is a product that generates sales of a billion dollars a year.  There are two important pieces of data that would be useful to complete the story.

The first is earlier ads with the term chemical imbalance. So far, I have two from 2001, but I am certain it appeared before that. I don't have time to search all of the popular literature.  If you subscribe to a magazine that has pharmaceutical advertising and keep all of the old volumes - take a look at the editions from about 1987 to 1995. If you see the term chemical imbalance please send me the image with the name and date of the periodical.  Let me know if you want credit for finding the image and I will give you full credit.

If you are a current or former pharmaceutical rep or marketing person and have access to any documents or videos with the chemical imbalance phrase please send it to me with the date it was being used. If you have recollections of how it was implemented and when I can also use that information but I am most interested in clear documentation like the videos I have posted. I have no interest in vilifying the pharmaceutical industry and understand the need for marketing and advertising.  I am just interested in the origins of this term and how it was implemented.

If you are an APA member and you were involved in the original National Depression Screening Day in 1990 - you may also have some information about this.  Please send it to me.


Supplementary 2:

All of the name brand drugs/medications mentioned in this post are currently generics or are no longer manufactured.  I have no affiliation with the original manufacturers or the generic drug industry.

Supplementary 3:

There are various Internet sites that attribute the term chemical imbalance to Pfizer or Lilly but they do not appear to be reliable - many appear to be antipsychiatry sites.  I would like to hear from people who were there at the time and can provide the necessary proof.  In those days (1986-1996) it would have been an internal memo or presentation.  Send me a copy if you have it.

Supplementary 4:

I had the opportunity to discuss this issue with a corporate attorney - especially the issue of available emails and memoranda dating back to 1987.  He told me that corporations hold this data only as long as the law states they needs to.  For example, if the law states the data must be held for 4 years it will be held exactly that long and then everything will be shredded.  If this information exists it will probably be in private hands.

Supplementary 5:

I got the expected low level feedback from a Twitter poster who thought he was making some point about this link on the Royal College of Psychiatrists web site suggesting that at least one of the causes of schizoaffective disorder was "a chemical imbalance".  I guess he really thought he had made me look foolish especially with the proclamation "You aren't psychiatry - they are."

In fact, I can't tell who wrote this and whether or not it is a psychiatrist. I don't know what the RCP official position is.  I was happy to see that they are much more flexible than the anti-psychiatry Twitter posters I encounter.  There was a feedback form that I completed and advised them to lose the "chemical imbalance" and that replacing it with "unknown etiology" was preferable. What I would like to see is an exposition of the latest theories and a suggestion that the critics actually read psychiatric literature.  They would be less likely to perseverate the same criticism they have used for year after year. This poster also seemed to ignore the fact that the RCP public information was posted in 2015 - that's 14 years after the television ad posted at the top of this page.  Royal College of Psychiatrists - the ball is in your court.

Supplementary 6: (added on 1/11/2020):  I just learned today from an advertising expert in antidepressants that there was also a Zoloft ad from 2004 that used the term: 

"While the cause is unknown, Zoloft can help.  It works to correct a chemical imbalance in the brain that may be related to these symptoms."


Cristina Hanganu-Bresch. Treat Her with Prozac: Four Decades of Direct-to-Physician Antidepressant Advertising in Drugs Media: New Perspectives on Communication, Consumption, and Consciousness (Hardback) (1st Edition) by Robert C. Macdougall (Editor), Drugs &. Media-Pasta Dura, 340 Pages, Published 2011 ISBN-10: 1-4411-1988-4 / 1441119884 ISBN-13: 978-1-4411-1988-9 / 9781441119889:


  1. "There is an exaggerated focus on the mechanism of action of medications used for psychiatric indications. I have never heard anyone say their doctor told them about the mechanism of action of antibiotics or even their blood pressure medications."

    My anecdotal experience is different. I've had plenty of patients tell me penicillin works because it is a fungus killing a bug, or that blood pressure meds cause them to pee or their vessels relax. Not most but some. Some patients are very interested in mechanism of action. If you have patients who or doctors, nurses, Ph.D.s this goes without saying.

    OK, we're making progress. At least we can agree that the paranoid position of the APA's pearl clutching Karl Rove/Levitry Beria spin and whitewash brigade, that this is a plant by "antipsychiatry" is false, unless Pfizer is the most diabolical Scientology double agent of all time.

    But if pharma started it, some psychiatrists definitely perpetuated it, or certainly didn't actively object to it for years, including at least three APA Presidents (as specifically cited) and a number of successful entrepreneurs as we discussed. Peter Kramer still seems to be hanging onto it. To the best of my knowledge, Reidbord is a good guy and hasn't joined SeaOrg.

  2. Well - if that is the penicillin explanation it is a new chemical imbalance theory for antibiotics. Some in my estimation is less that 5%. They might be health care professionals but I have also seen plenty of HCPs who were ill informed about their medical diagnoses and did not know the names of their medications. That is probably because they just take for granted the fact that they have a legitimate medical diagnoses that is being treated with a real medication. In fact, at least 20% of antibiotics are overprescribed for viral infections and a multi-decade initiative of the CDC has not put much of a dent in that.

    Actually I think there is very little that we agree on. I don't think there is any Deep State within psychiatry and in fact the frustrating part for me has always been that organized psychiatry has NEVER chosen to defend itself or even assert itself. That is one of the reasons for this blog. Whenever I have confronted leaders in the APA I have heard excuses about everything from needing to avoid litigious cults to just a lack of interest by the leadership. In the case of MOC, the response was just distortions about how much this was needed when I pointed it was a cash cow for ABPN.

    Since I am one of the few people doing this - I will also clarify that antipsychiatry groups clearly use this advertising meme against psychiatrists and psychiatry in general. I never suggested that they started it. I have the link in one of my original posts linking to statement by G√łtzsche.

    If you want to see Peter Kramer's response to the Zoloft ad it is right here:

    Another couple of areas we don't agree on include the general classification of antipsychiatrists. I think there are clear criteria and each group or individual can be responded to based on their rhetoric. I don’t find one group to be more unique than the other. If it quacks like at duck, etc.

    I am not opposed to Pharma advertising - it is a standard business practice in the US and every American citizen needs to heed the old adage "Let the buyer beware." That applies doubly to health care. The sanctimonious think that Pharma companies need to be held to a higher standard than other corporations and for the most part they are. As I read the FDA actions and drug regulation the current goal is to get reasonable safe and effective drugs into the hand of clinicians. For the most part that succeeds. That does not mean that their marketing departments don’t act a strictly business rather than science centered way at times.

    If some psychiatrists perpetuated it they need to stop and develop a more enlightened approach. It is really that simple. That is another focus of this blog.

  3. "Another couple of areas we don't agree on include the general classification of antipsychiatrists. I think there are clear criteria and each group or individual can be responded to based on their rhetoric. I don’t find one group to be more unique than the other. If it quacks like at duck, etc."

    There are clearly different categories, approaches and motivations of the critics.

    Scientology thinks psychiatry just plain evil and want to shut it down, and that it's competition.

    MIA are disgruntled former patients. They feel like victims.

    The late Mickey Nardo and Bernard Carroll (you might even put Allen Frances in this group) are clearly mainstream psychiatrists who are upset about trends and falsehoods in psychiatry.

    Then there are groups on nonMDs who think that medication is overused or should not be used at all.

    I think they are quite unique and different in purpose, motivation, style, etc. You're not putting Bernard Carroll in the same category as David Miscavage, I hope?

    Criticism isn't anti anything on its own. It is the duty of every good scientist to be constantly critical of their own work, discovering flaws in theory and practice. The opposite is zealotry.

    I see chemical imbalance, frankly as a venial sin compared with others so it mystifies me why we can't own up on that. The research ghostwriting, Paxil 329, child bipolar, abuse of ADHD to improve SAT scores, DSM5 etc. We're always asking patients to own their failures and improve, it would be nice to set a good example.

    I don't think psychiatry is monolithic at all, but I do think APA is not representative of general psychiatry, but of the mindset of academic prestige climbers whose social lives are too tied into their profession.

  4. "The late Mickey Nardo and Bernard Carroll (you might even put Allen Frances in this group) are clearly mainstream psychiatrists who are upset about trends and falsehoods in psychiatry."

    None of these psychiatrists are antipsychiatrists.

    I have corresponded with the late Drs. Nardo and Carroll many times and Barney has sent me references. I had minor disagreements with Dr. Nardo and major disagreements with Dr. Frances that are actually posted on this blog.

    I can argue with people and not call them names. When I say something is from the antipsychiatry crowd - you can take it to the bank. Nothing from these psychiatrists ever was.

    Disagree completely about MIA based on the organizer.

    The APA is no more representative of General Psychiatry than the AMA is representative of General Medicine. All political organizations in this country have a life of their own. Ask any member who gets into trouble and turns to them for help. I had the APA turn on me when I asked them a simple question about the legal aspects of prescribing bupropion when it was contraindicated by the FDA. I got an email from their attorney asking me if I was qualified to prescribe it. Clearly the APA prioritizes the survival of that organization over any psychiatrist. They were no help at all in that situation and neither was the FDA. I changed jobs when the health care organization I worked for decided to turn on me. Again, the nature of political organizations in this country.

    At the same time the APA (stereotyped as monolithic psychiatry) does not deserve the abuse that is heaped on it. Photo essays and commentaries about all of the Pharma funds sent to the APA minimize the fact that as far as industry funding it is intermediate compared to other medical specialty societies and psychiatrists are way down the list as individual recipients of that money.

    People don't hear that from the AMA or APA. They are both politically inept as far as I can tell. But they do hear it here.

    I say it because that is the way it is. My colleagues are good people. They know what they are doing. They work hard and do good work. They are interested in helping their patients. And probably because I have blue collar roots and was taught to not play nice and network with people who are treating you badly.

    I had a psychiatrist introduce herself to me at a local conference and when I told her who I was she said:

    "Oh you're the guy who says what we all want to say but never will."

    That may be the best compliment anyone has ever given me.

  5. Very good. Not all psychiatric criticism is antipsychiatry and it is certainly not at all the same. Much of it is necessary and constructive. We seem to actually agree.

  6. I know I should not dive into this discussion but, I really feel compelled to just note, that the DSM-5 was such a blatant sell-out by the creators to find new and creative ways to justify the use of psychopharmacology for grey zone issues.

    Maybe you've commented on this already Dr Dawson, and I'm sorry I haven't read through your archives to find your positions, but, the DSM-5 is a travesty and it plays into this issue of biochemical imbalance as a primary factor to mental illness.

    Just my opinion, but, again, I've been traveling around, and I have a lot more interaction with colleagues than I think you do Dr Dawson, per clinical work time, so I don't think you can just dismiss me so quickly as I find you do.

  7. "DSM-5 is a travesty and it plays into this issue of biochemical imbalance as a primary factor to mental illness."

    That is not the history of the DSM at all - but that is familiar antipsychiatry rhetoric.

    For what really happened I would suggest reading a single paragraph in DSM-5 on page 6 called "A Brief History".

  8. FWIW I don't think there is a deep state in psychiatry either. Otherwise I wouldn't have the nerve to be writing this. They are basically powerless and ineffective, not powerful and devious.

    They do take stands but have misplaced priorities. Many of their stands are defensive, or outside their area of expertise and amount of virtue signaling. The APA convention last week was a combination of endless Vraylar ads and many seminars on global warming (I understand the irony of experts flying from all over the world to hear this way off-topic stuff, but apparently they don't. Didn't anyone raise their hand and suggest a teleconference?), but very little on what to do about the homeless mentally hordes not far away in the Tenderloin. That is JOB ONE.

    All of this suggests to me that the real priorities (based on actions not words) is pharma money, wokeness and virtue signaling and not the real job of psychiatry. But I do give them credit for validating the Dunning Kruger effect.

    The fly to a city with a convention center, leave work, spend five grand , get seduced by pharm reps, and drop a huge carbon footprint model of medical education is anachronistic. I really do wish they'd have the decency to teleconference it and at least be consistent on the issue of CO2.

    1. Local DB scientific conferences are probable the way to go. Much smaller carbon footprint and that psychiatrists there are directly relevant to your practice.

      I am currently slogging through the HMS free addiction course. It is excellent but as time consuming as sitting in a Boston Hotel conference room with 300 other MDs taking it real time.
      Except you can speed up the video and that is an interesting option. You can download all of the PowerPoints.

      I have asked them to put all of their courses online. I would pay to take them that way, but not the full price for being there in person.

      You can also purchase access to the APA and Have been able to do that for years on CD. The cost is $1,000 and it is usually 40 CMEs.

      Another factor going online are employer related incentives. CME time off carries the implication that you are going somewhere and sitting in lectures. In previous employment, several colleagues resented the fact that I took a week off to do the CME exercise for the first ABPN Geriatric Psychiatry recert course. There needs to be a much more enlightened view of online CME.

  9. I wasn't kidding about Vraylar at the APA:

    I'd comment about the house of cards at the Vraylar exhibits but it's just too much of a softball that it's not even fair.

    1. Interestingly I did this at a previous APA convention in SF in 2009. I have about another 30 photos if I can find them. I have had two major computer changes since then. I would be surprised if third generation antipsychotics make as much money as older versions. Most clinical psychiatrists find it impossible to get lurasidone for their patients through prior authorization.

      Seroquel XR is currently generic but I have hardly seen it prescribed. That highlights the short longevity of product cycles at "trade shows" whether it is Pharma or electronics.

  10. Key excerpt:

    "My favorite was Subvenite®, which is just lamotrigine in a conveniently-packaged box that tells you how much to take each day. The same amount of normal lamotrigine would cost about $12; it’s hard for me to figure out exactly how much Subvenite® costs, but this site suggests $540. To be fair, lamotrigine is a really inconvenient drug whose dosing schedule often leaves patients confused. To be less fair, seriously, $540 for some better instructions? Get a life."

    We complain about PBMs, but this is why they exist.

    The meeting seems to have been a disturbing amalgam of the worst of the extreme right and left: crass big money commercialism (I'm a capitalist not a corporatist) combined with extreme PC.

    Buddhism has some good advice: follow the middle path.

    But there's no money in that.

    1. Subvenite appears to be using the AdVair Diskus strategy. Asthma inhalers in general use medications that have been around for decades and either combine them or use novel doses. That is a well known Pharma strategy.

      The critical link is not the PBM but the psychiatrist who knows that an expensive medication rarely needs to be prescribed. PBMs currently interfere with generic prescribing and of course MDs are pawns in Pharm and PBMs continuously gaming the system for profit. That dynamic is ongoing whether or not these companies construct elaborate displays at medical conventions.

      Back in the 1980s - I saw a laser light show at the LA convention inscribing a large XANAX tablet on the wall of the convention hall. After that I prescribed XANAX to one patient and concluded it was a bad idea to treat anxiety with a drug that reinforces it's own use. Of course as an addiction specialist I have seen many people who I was supposed to help to get off of it.

      I have not prescribed a single dose of Silenor, but I have prescribed a fair amount of the lowest dose of generic doxepin. But I inform those patients of both options.

      The criticism of these Pharma trade displays carries the implication that physicians are mindless automatons prescribing whatever Pharma wants us to. If that were true - many of the drugs I encountered in my trip to the Biomed library would still be out there on the market, there would be less discount pressure on generics, and there would be no ongoing critique and analysis of medication prescribed by physicians.

      Advertising is advertising - I have never found a reason to get too worked up over it. I always wonder about the motivations of people who do get worked up over it.

  11. It's axiomatic that these companies wouldn't be advertising if it didn't work.

    I'm not so sure physicians are that great at resisting the lure of advertising and are really that great at critical thinking. Most have no idea about epistemology.

    Critical thinking isn't really much of an asset in medical school and training which has become an endless exercise in regurgitating Powerpoint propaganda.

    There is much in the psychological literature to indicate that high IQ people (physicians average 115) are still as emotionally influenced as the average person in their decisions. It's the old elephant and rider analogy, and emotion is the elephant. Intellect serves to rationalize the emotional choice, not to drive the decision based on analysis.

    A perfect example outside of psychiatry is clinical nutrition. Physicians have fully accepted 80 years of completely unscientific industry sponsored drivel (7 servings of grain a day?) for no other reason that it was repeated forcefully and often, Soviet style. The result is a health disaster of obesity, DM and probably dementia. Japan has a 3.5% obesity rate, by contrast.

    I'm not "worked up" about the ads, except aesthetically as they are grotesquely tacky (does it have to be on every stair?). I'm far more concerned the physicians and psychiatrists have in fact become automatons controlled by industry and academic hegemony. I don't blame them as much as the reward/punishment system of medical education. Which are run by the same people who run the APA.

    Pharma adverts are on TV are probably the most honest, since the side effects are spelled out.

    I think our basic difference is that I think the general public is smarter and the average physician not as smart as you do. At least in terms of using dispassionate analysis rather than emotion in decision making.

    Psychiatrists can prove to me that they are not automatons by not constantly jumping on every stupid intellectual fad. I seriously wonder how many of us were convinced that the Bay City Rollers were the next Beatles in 1976.

    1. Of course advertising works - that is why all businesses do it.

      For the past ten years working in a tertiary care setting I see all of the people coming in on psychiatric medications. Few people have seen psychiatrists but about 60-70% are treated for some kind of psychiatric disorder. Since we lack the capacity to treat people with severe mental illnesses we are seeing depression, anxiety, insomnia, bipolar disorder, and a significant number of drug induced states.

      The inappropriate prescribing generally involved reasons for admission like opioid, sedative hypnotic or stimulant use disorders. Practically all of those medications are generics.

      The typical antidepressants and other non-addicting agents used are overwhelmingly generics. The off formulary exceptions are vortioxetine and several newer antipsychotics. Lurasidone requires prior authorization. I stand by my assertion that the prescribing landscape does not contain a lot of heavily hyped and expensive drugs. I have not seen a single person come in taking VRAYLAR® (cariprazine). Once our EHR is sorted out maybe I can document and publish that for what it's worth.

      Regarding emotionally influenced reasoning - Antoine Bechara has illustrated that all people need this component. Functional disconnections of emotion result in severe disability due to an inability to make decisions even when a normal IQ is preserved.

      For the last 20 years, every CME event whether it is sponsored by a Pharma company or not has as part of the evaluation: "Was this course/event free from commercial bias?" The response to that question has been an overwhelming "No."

      Once again - you have a dim view of psychiatrists and other physicians and I do not. I don't consider them to be automatons or needing to "prove" anything to me. The physicians I know are some of the brightest and highly motivated people I have met and I am an introvert not interested in meeting many people.

      With that kind of a core conflict there is really not much to discuss. I don't expect to change your mind and you should certainly have the same expectation about changing mine.

  12. Fair enough. What percentage of psychiatrists or psychologists would you recommend to a family member?

    Physicians are well above average in intelligence and hard working and conscientious. Most are not geniuses (that's statistically provable) or outside the box critical thinkers. By and large they are conformist. That's why the takeover of health care was so easy.

    1. It is really not a question of percentages.

      When my wife had a pituitary adenoma wrapped around her internal carotid artery we found the best surgeon for the job. I did the same for three surgeries last year.

      I am constantly asked for referrals to psychiatrists and the only limiting factor is access.

  13. Whether they are bright or genius doesn't matter anyway. My original point was that the decisions that people make are emotionally driven then rationalized intellectually. This wasn't meant as an intelligence insult but an observation on human behavior. Once again I think you missed my point as you are focused on identifying perceived insults.

    Physicians are often horrible in real life decision making. It's a fact they invest poorly and make poor business decisions. If they had been less frightened and less conformist/agreeable about the changes in medicine, they wouldn't be in the situation they are in. APA Presidents have been elected after they were in major scandals, and that doesn't help things.

    1. Well actually I don't know how I could have missed your point if I reference the body of work on the neurobiology behind emotional decision making. I don't think you are teaching me much about the process.

      The only thing we agree on is that physician political organizations are inept. I don't think that translates to physicians being horrible real life decision makers compared to anybody else. It all goes back to the core conflict I alluded to above and this is just an extension of that argument.

      No need to continue it.

  14. I wonder how we explain the large following among psychiatrists of Hagop Akiskal and Joseph Biederman, who seem to think that having a temper tantrum is a symptom of bipolar disorder, and who medicate their patients accordingly. I have no idea if this is happening where you all are, but it's rampant here in Memphis. I saw a patient who had been diagnosed as bipolar by the local hospital because of one symptom: a spending spree. She was spending money on cocaine!

  15. If an APA participant or lecturer flew business from New York to San Fran to attend global warming lectures and workshops over four days, that would expend 4.3 metric tons of CO2 round trip according to a carbon footprint calculator I used. Worldwide the average person releases 4.5 metric tons and in the US 17.5 metric tons. So one year of emissions to preach the opposite of what is practiced. This is basically the insanity of Emma Thompson flying from LAX to Heathrow to join AGW protestors shutting down holiday flights, which recently happened.

    This is what I meant by emotion trumping analysis. Even bright people are more motivated by prestige and money than logic. Which should not be surprising to anyone.

    But if any group should stop and think about what they are doing, we should be doing so to set a good example. It would have been far less hypocritical and enlightened to teleconference the event as well. Teleconferencing systems are really good today and I don't even buy the argument that you need to be there in person to broaden social and referral networks.

  16. Misdiagnosis of bipolar disorder is common is patients with substance use problems. It is also a difficult diagnosis to make especially if the person has been continuously using substances for years or decades. I have seen bipolar disorder emerge during initial abstinence of 60 - 90 days to the point that any reasonable clinician would treat it.

    The other common scenario in treatment settings is the following comment: "Don't blame my doctor/psychiatrist - I never told them I was using (EtOH, cocaine, meth, cannabis, etc).

    On the issue of anger and tantrums being misdiagnosed as bipolar disorder - the best antidote is to figure out if the person has had DSM-5 manic episodes. People criticize the book, but without an actual manic episode as described - you don't have bipolar disorder. I saw an excellent presentation on that by Kenneth Towbin, MD:

    See what he says about it in contrast to Biederman, but basically anger or irritability by itself is not bipolar disorder. His statements are based on determining outcomes based on observing what happened on research units where length of stay was not an issue. I have seen the same patterns in kids who were placed in foster care and then developed adult mood regulation and could look back and not say what they were angry about.

    1. I've defended Big Pharma from baseless attacks. I wouldn't be alive without them. Many of us wouldn't. I think I can criticize them though without biting the hand that saves me.

      But we have to admit the current paradigm for development of CNS drugs isn't working if we've gotten to repackaging and price hikes as the next great thing.

      I think there ought to be a tradeoff by eliminating Phase 3 trials and extending patents for a cap on pricing based on a percentage over R and D. Maybe a prize system that worked for the discovery of how to figure longitude. The current system is not sustainable and we are not making progress.

    2. This particular patient had no other symptoms suggestive of mania besides the alleged "spending spree," and she admitted to the cocaine use. If the psychiatrist had observed her for just a few hours, the fact that she was not manic would have become even more readily apparent. But no one kept looking. This sort to thing is NOT an unusual occurrence here. The DSM criteria (especially the duration criteria) are routinely ignored, despite being IMO very accurate for bipolar disorder if evaluated even somewhat similarly to doing an SCID interview.

    3. Recommend they bring in Dr. Towbin for a CME event.

      Or better yet - why don't you do it. Could not agree with you more on the duration criteria. If people actually read the DSM they might also be shocked to find:

      "Major depressive disorder may also be accompanied by hypomanic or manic symptoms (ie. fewer symptoms or for a shorter duration than required for mania or hypomania)...." p. 131 par 3.

      I routinely see people with depression who have had these symptoms usually for hours but occasionally 24-36 hours. They don't have bipolar disorder.

      People can say what they want about the DSM but it certainly nailed down the criteria for bipolar disorder.

    4. I have already
      lectured about this, but even a couple of my former trainees (I was a residency director for 16 years) ignore what I say, while the local Akiskal devotee tells them the DSM criteria are full of it, and tells psychiatrists they shouldn't even ask about duration. One of my patients with borderline personality told me that the people hospitalized at the local psych hospital themselves joke about all the "diagnonsense" going on.

      The biggest part of the problem is that the hospital knows it is much more likely to get paid by insurance companies if patients are diagnosed with bipolar disorder and not borderline personality disorder. I don't know for sure, but I think they put a lot of pressure on doctors to do that.

    5. This has been going on forever. I remember in the mid-eighties when adolescent conduct disorder magically transformed to major depression because mangled care stopped paying for conduct disorders. Mangled care, the mortal enemy of inpatient psych that one ONE APA President bothered to oppose. But that's the fault of the APA rank and file who are content with it being an ineffective guild with very expensive CME.

  17. and on cue, from my perspective, the WHO is now listing "burnout" as an official medical diagnosis.

    So, let's see if the basic premise to this as an alleged psychological disorder isn't approached as a biochemical imbalance; let's see if responsible clinicians want to have patients come in and do good therapy work, or, just have medications thrown at them and then told to go back to work...

    1. I think this may be the first of many game changers, certainly in Britain:

      A year ago NHS was pushing heavily for more people to be on SSRIs.

    2. Won't make any difference in the people I see. In fact - I advise them to go on the Internet and look at all of the antidepressant side effects that they want.

      Has not affect that decision any more than my decision to take flecainide - even when I knew a clinical trial was stopped because patients treated with active drug had a higher rate of death from arrhythmia than the patients on placebo.

      A focus on side effects especially the adversarial way it is described in this newspaper article as a "win" minimizes the suffering that people are experiencing and the fact that they are desperate to do something.

      The idea that psychiatrists are "dismissing" side effects when in fact they are the people treating them is hyperbole.

  18. In light of old and recent developments and focus on discontinuation syndromes, as well as the jaundiced research sponsored by Glaxo, I have no idea why Paxil is still used in practice. Merital and Serzone were canned for a lot less.

    1. Agree - I stopped using it decades ago.

      I liked Vioxx (rofecoxib) although it was apparently voluntarily withdrawn and zomepirac.

  19. The assault on the COX-2s was ridiculous. It was a nice tool to treat pain between the effectiveness of NSAIDs and opioids without running into the problems of opioids. I wonder how the epidemic would have turned out had they still been around.

    1. I hardly see any primary care MDs prescribing CELEBREX(celecoxib) but imagine they are limited by PBMs. On the other hand naproxen is cheap and I see a lot of people taking 500 mg BID indefinitely.

      I have had recurrent gout attacks since medical school and went from indomethacin to 220 mg naproxen to stop acute attacks. But only because they took Vioxx off the market. Vioxx would stop it in 1 or 2 doses without the side effects of indomethacin or naproxen.

  20. Apparently there's a company that wants to bring Vioxx back specifically to treat hemophilic arthopathy. You can't use NSAIDs with that population for obvious reasons so the only thing left is opioids Once it gets an indication it might be prescribed off label, so there may be a way.

    1. Now that I think about it, if this argument flies, why not just approve it for people who are intolerant to NSAIDs? How many people died from Vioxx cardiac events vs. NSAID related GI bleeds?

    2. My guess would be a lot less. If I am recalling correctly I have seen UGI bleed from NSAID mortality at 3500-5000/year. And of course there are the renal problems as well.