Read This Critique!

 

Today was a good day for psychiatric criticism. An “Umbrella Review” that essentially declared that serotonin was dead in psychiatric research (1) has essentially been refuted (2). I do not want to mischaracterize the authors conclusion so here it the direct quote from the original paper.

“This review suggests that the huge research effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis to depression. …  We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.” (1)

Ron Pies, MD and I (3) noted several problems with the paper on a historical and rhetorical basis and penned a response based on those elements of the paper.  The authors used the terms “serotonin theory” and then “chemical imbalance theory” interchangeably in the paper.  We knew that the former was a hypothesis at best and the latter really did not exist as either a hypothesis or theory in the psychiatric literature. We referenced 4 reviews of the serotonin hypothesis from 1954 to 2017 and the results that the total evidence was inconclusive or inconsistent.  We included historical quotes to illustrate that researchers investigating neurochemistry were fully aware of the complexity of psychiatric disorders and that even clear-cut evidence of a finding implicating a neurotransmitter would not rule out environmental or psychological factors in the etiology of depression.

We also discussed the complexity of serotonergic systems in the brain and the fact that it is an ongoing focus of extensive research and ongoing publications. The only possible conclusion is that the science around serotonin is not settled and that needs to be recognized.  I put a post on my blog and hoped to move to a methodological focus on the paper but never got that far.

A group of scientists and psychiatrists was able to do that in a publication today (2).  This paper is available online and I am not going to repeat their evidence or conclusions when you can read it yourself at the link below. It is a very brief paper and I highly recommend reading it. This group found substantial methodological problems with the paper and concluded that there were substantial errors and misinterpretation of the data in the original paper.  Their conclusion was the errors prevent readers from drawing any “reliable or valid conclusions" and:

“A more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed. The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position.”

The most striking aspect of this critique is that it is authored by 35 scientists – many of whom are also psychiatrists. I have read papers written by many of them on aspects of the neurobiology of the human brain in various experimental settings.  There are experts in neuropharmacology and neurobiology.  The word brain trust comes to mind when I think about a group who could have written a response to the umbrella review or even the original review itself.  In addition to the neuroscience expertise – one of the authors wrote the reference on rules for conducting an umbrella review (4). There appears to be no equivalent expertise in the original paper, and in fact very few papers have that level of expertise.  Let me conclude with some observations based on the current critique:

1: Rhetoric is an important part of both general press and scientific literature.  The authors of the original Moncrieff review are all on record as supporting positions well outside of mainstream psychiatric education and practice.  To cite an example, I critiqued a paper by Middleton and Moncrieff on this blog where I also outlined various examples of philosophical, statistical, medical, and neuroscience rhetoric that essentially could have predicted the original umbrella review and both the response by Pies and I as well as the response by Jauhar, et al.   It is probably a good general policy to avoid entrenched positions when doing systematic reviews and if that is not possible to stick to clear guidelines for objectivity.

2:  The paper today was a welcome return to what psychiatrists everywhere know to be accurate and that is serotonergic systems and the brain in general are complex and the story is incomplete at this point. For the public – proclamations about causes and mechanisms are speculative apart from the evidence reviewed in today’s paper.  When you read speculative news stories about psychiatry (they generally all are) maintain a high degree of skepticism – especially if you have found something that is working for you – in this case for depression.  Always discuss what you read in the papers with your physician before making any changes. 

And for professionals, expertise still means something. With a proliferation of meta-analyses and systematic reviews being published it is evident that many authors have never done research in the field they are attempting to analyze. There is no substitute for experience doing the research and being very familiar with the literature and experimental methods in that field.  It is much easier to criticize a clinical trial than to actually do one. That is not just my experience and opinion.  Ioannidis has concluded (5): "The production of systematic reviews and meta-analyses has reached epidemic proportions. Possibly, the large majority of produced systematic reviews and meta-analyses are unnecessary, misleading, and/or conflicted." (see the graph below for an update)

3:  Several people today suggested the “damage has been done” by the original paper and there is certainly some evidence for that.  There were some suggestions that the original paper will be retracted, but I do not see that happening. Critics of psychiatry always get much more leeway than the comparatively fewer critics of other specialties.  There are many glaring examples, most notably the Rosenhan paper about psychiatric imposters - even though it was decisively critiqued at the time of its publication and subsequently shown to have been based on highly problematic and in some cases false research.  That original paper remains in a scientific journal.

4:  The profession and this journal are fortunate for the coordinated efforts by this group of authors.  It will hopefully serve as a template for responding to similar pieces in the future. I read a lot of papers in psychiatric journals and the quality of what I read is generally not very good.  Even flagship journals are publishing articles that are basically opinion pieces that call for significant modification of the entire profession. These are all typically arguments that involve author(s) attempting to control the premise of an argument.  I have read premises that are either blatantly false or unprovable and somehow these pieces are published in journals for psychiatrists. I also read medical literature and apart from the usual pieces claiming proclaiming the greatness of managed care and administrators in the American healthcare system – there are no calls for broadly reforming any other specialty. Like every other psychiatrist out there, I went to work for 35 years and was able to make a difference by helping people, doing research, and teaching in very taxing environments. Editing and peer review both need to improve - but in an environment that encourages excessive publishing it is doubtful that either will occur. 

5:  This is also a teaching and learning moment. Resident and faculty research seminars will benefit from reading both papers and reviewing the implications.  Some of those implications include questions about why it is so easy for people both inside and outside of the professional to suggest major departures in the intellectual trajectory and practice of the field and why that does not happen in any other medical specialty. 

If someone makes a claim that the field needs an immediate change in its intellectual focus or practice – there needs to be a compelling reason.  To paraphrase Carl Sagan – extraordinary demands require extraordinary proof.  We are still waiting for the extraordinary proof for serotonin, but there is some.  Proclaiming serotonin as a dead end was as big a mistake last year as it was 8 years ago.

 

George Dawson, MD, DFAPA

 

 

 References:

1: Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry. 2022 Jul 20:1-4.

2:  Jauhar S, Arnone D, Baldwin DS, Bloomfield M, Browning M, Cleare AJ, Corlett P, Deakin JFW, Erritzoe D, Fu C, Fusar-Poli P, Goodwin GM, Hayes J, Howard R, Howes OD, Juruena MF, Lam RW, Lawrie SM, McAllister-Williams H, Marwaha S, Matuskey D, McCutcheon RA, Nutt DJ, Pariante C, Pillinger T, Radhakrishnan R, Rucker J, Selvaraj S, Stokes P, Upthegrove R, Yalin N, Yatham L, Young AH, Zahn R, Cowen PJ. A leaky umbrella has little value: evidence clearly indicates the serotonin system is implicated in depression. Mol Psychiatry. 2023 Jun 16. doi: 10.1038/s41380-023-02095-y. Epub ahead of print. PMID: 37322065.

3:  Pies R, Dawson G.  The Serotonin Fixation: Much Ado About Nothing New. Psychiatric Times. 2022 Aug 22.

4: Fusar-Poli P, Radua J. Ten simple rules for conducting umbrella reviews. Evid Based Ment Health. 2018;21:95–100.

5:  Ioannidis JP. The mass production of redundant, misleading, and conflicted systematic reviews and meta‐analyses. The Milbank Quarterly. 2016 Sep;94(3):485-514.  https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12210

Supplementary:

To update Ioannidis observations on the systematic reviews (SR) and meta-analyses (MA) versus randomized clinical trials (RCTs) I pulled up searches for those types of studies on PubMed and graphed them below.  The 2023 numbers are incomplete and that results in the tailing off of the graph on the right. The numbers of SR + MA compared with RCTs is striking. For the last complete year of data (2022) there were 38,422 RCTs compared with 42,738 SR and 36,614 MA.  As you might be able to estimate from the graph the inflection point where the annual production of RCTs were exceeded by SR + MA is relatively recent in about 2017, but the growth of these two groups has been exponential over the past 20 years.   That suggests to me that it is easier to talk about research rather than doing it yourself.

 

Graphics Credit:

Thanks to my colleague Eduardo Colon, MD for the sunrise photo.

 

The arbitrary and often absurd rhetorical attacks on psychiatry

 

I drew the above graphic (click on it to enlarge) to highlight a few things about popular psychiatric criticism, but mainly that it is absurd.  I have commented on antipsychiatry rhetoric many times in the past and how it has a predictable pattern.  But this goes beyond antipsychiatry to include critics in the press, authors selling books (or being paid for lectures or appearances), and even critics in the field. I thought it might be useful to try to crowd as much of this rhetoric into one diagram as possible for easy reference.

Why is rhetoric so important?  Rhetoric is all about winning an argument.  The strategies are all well documented and you can read about them and the common fallacious arguments in any standard rhetoric or logic text.  My goal is not to teach rhetoric.  For the purpose of this post, I want the reader to understand that there is more rhetoric leveled at psychiatry than any other medical specialty. There is always a lot of speculation about why that might be – but nobody ever seems to come out and say the most obvious reasons – gaining political advantage or financial renumeration. There is also dead silence on the questions of facts and expertise - since practically all of the literature out there including much of the rhetoric advanced by psychiatrists is an overreach in terms of psychiatric knowledge and expertise.  When absurd rhetoric about psychiatry makes the New York Times or even prominent medical journals it is simply accepted as a fact. There is no marketplace of ideas approach or even a single alternating viewpoint. Some of the statements in the graphic are taken directly out of newspaper articles and they are absurd. 

I happen to believe that the best critiques of the field come from people who are experts and usually do not deteriorate into ad hominem attacks against the field or other experts in the field. I was trained by many of those experts who consistently demonstrated that a lot of thought and work goes into becoming a psychiatrist and practicing psychiatry. I have known that for 35 years and continue to impressed by psychiatrists from around the world who contact me every day.     

I sought feedback from psychiatrists through several venues about absurd psychiatric criticism, by showing them a partially completed table and asking for suggestions.  One suggestion was making a grid to evaluate plausible, implausible, and unproveable. I do not think that is the best way to analyze these remarks. There seems to be a lot of confusion about rhetoric versus philosophy and a tendency to engage in lengthy philosophical analysis and discourse. It turns out that a lot of what passes for philosophical critique of psychiatry is really rhetoric.  That rhetoric generally hinges on controlling the premise and arguing from there. For example – the statement that the DSM is a “blueprint for living” is taken directly out of a New York Times article where the author – a philosophy professor was critiquing the 2015 release of the DSM-5 on that basis. Never mind that no psychiatrist ever made that claim or even had that fantasy – there it was in the paper written like the truth. A reading of the first 25 pages of the manual would dispel that notion but it is clear nobody ever seems to do that. 

I seriously considered modifying the diagram based on a division proposed by Ron Pies, MD (1).  That would have involved dividing the area of the graph into a zone of “legitimate criticisms focused on problematic areas in psychiatry” versus “fallacious and baseless attacks ... aimed at delegitimizing and ultimately destroying psychiatry.”  As I attempted to draw that graph – I realized that I could not include any of the current statements in a legitimate criticism zone.  In order to do that I will need to find an equivalent amount of legitimate criticism and include it in a new graph.

This rhetoric has much in common with misinformation, except it has been around for decades. It is not an invention of the Internet or social media. An important aspect of rhetoric is that since it does not depend on facts it can be continuously repeated. That is the difference between the truth and facts versus rhetoric. The classic modern-day example is the Big Lie of the last Presidential campaign. Former President Trump stated innumerable times that the election was stolen by election fraud and at one point suggested that there was enough proof that it allowed the Constitution to be suspended. All that rhetoric despite no independent corroboration by any judiciary or election officials from his own party.  Major news services began reporting his claim as a lie.  Recent news reports revealed that the stars of the news outlet that Trump was most closely affiliated with - did not believe the election was stolen. Many of the statements leveled at psychiatry in the table are equivalent to the Big Lie.

Rhetoric typically dies very hard and that is why it is an integral part of political strategy. A current popular strategy is to use the term woke as a more pejorative description of politically correct. It creates an emotional response in people “You may be politically correct but I am not.”  The term is used frequently to describe many things including the teaching of Critical Race Theory (CRT) in public schools. Repetition alone has many Americans believe that CRT is being taught in public schools and that is something that they should actively resist. The fact is – CRT is not taught in public schools and yet the effect of the rhetoric has been enough to leave many people outraged and susceptible to political manipulation. The rhetoric itself is difficult to correct by a long explanation about CRT.  That approach will not win any arguments. The best approach is to characterize it for what it is at the outset – absurd rhetoric that is not reality based. But there is a good chance that will also not have much impact.

When I talk with psychiatrists about the problem of not responding to rhetoric – I typically encounter either blank stares, the rejoinder that “there might be a grain of truth there”, or  the suggestion that we should just ignore it and it will go away. Physicians in general seem to be clueless about the effect of politics and rhetoric on medicine and psychiatrists are no exception.  When you are trained in science and medicine, there seems to be an assumption that the scientific method and rational discourse will carry the day.  That may be why we were all shocked when the American people seemed to be responding in an ideological way to public health advice during the pandemic and they were so easily affected by misinformation. 

Rhetoric in science predates the pandemic by at least a century.  It has been suggested that Charles Darwin used natural selection as a metaphor for domestic animal breeding (1) in order to convince the predominately religious people and scientists of the day.  He had to argue the position that unpleasant natural states were intermediate steps leading to a more advanced organic state.  Without that convincing argument Darwin’s theory may not have received such widespread acceptance in the scientific community. It is useful to keep in mind that just presenting the facts is not necessarily enough to win an argument especially in the post truth environment that exists in the US today.

The “grain of truth” rhetoric is typically used to classify, generalize, and stereotype and may be more difficult to decipher than straightforward ad hominem attacks. A typical “grain of truth” argument in the graphic concerns pharmaceutical money being paid to psychiatrists and other physicians. Some psychiatrists are employed by pharmaceutical companies to conduct clinical trials and other business, some provide educational lectures, and more are passive recipients of free continuing medical education courses.  All of this activity is reported to a database where anyone can search how much reimbursement is occurring. From this activity it is typical to hear that psychiatrists are on the pay roll of, get kickbacks from, or are brainwashed by Big Pharma and KOLs (Key Opinion Leaders).  The reality is most psychiatrists have no financial conflict of interest and they are not free to prescribe new expensive medications because those prescriptions are controlled by for-profit PBMs (pharmacy benefit managers). Further – the entire issue was highlighted by a No Free Lunch movement that provided essentially rhetorical information about conflict of interest and how it affected prescription patterns.  Those arguments have a very weak empirical basis. 

What about just ignoring this rhetoric? Ignoring it has clearly not been a successful strategy.  Any quantitative look at antipsychiatry rhetoric and literature would clearly show that it has increased significantly over the past 20 years – to the point that papers written from this standpoint are now included in psychiatric journals and you can make money doing it.  Recent cultural phenomena including the Big Lie rhetoric of the last Presidential election, the partial recognition of climate change (despite firsthand experience with increasingly severe weather most do not believe it is due to human activity), and the multilayered problematic response to the coronavirus pandemic sends a clear signal that rhetoric must be responded to and not ignored. 

The American public has been fed a steady diet of absurd criticisms about psychiatry for decades. If you do not believe that – study the table and compare it to what you see in the papers and across the Internet.  And never take anything you read about psychiatry at face value.

 

George Dawson, MD, DFAPA

Supplementary 1:  As noted in the above post I am interested in graphing legitimate psychiatric criticism in the same format used in the above graphic. If you have critiques and references - feel free to post them here.  I have some favorites from Kendler, Ghaemi, and others. 

 

References:

1:  Pies R.  Four dogmas of antipsychiatry.  Psychiatric Times May 5, 2022:  https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry

2:  Herrick JA. The History and Theory of Rhetoric. 7^th ed. New York, NY: Taylor and Francis, 2021: 221-223.  – I highly recommend this book on the historical and current importance of rhetoric. A lot of what passes for philosophical criticism of psychiatry is really rhetoric.

The Bureaucratic Takeover of American Psychiatry

 

This interview was posted on the Psychiatric Times web site today.  It contains bit and pieces from blog posts here over the past 8 years. It is a rare opportunity for people to see what is wrong with American psychiatry and that is - it is not run by American psychiatrists. It is run by managed care companies, pharmaceutical benefit managers, and government bureaucrats who all have the common goals of restricting access to psychiatric services.  And by psychiatric services, I am including substance use disorders and their treatment as well as the considerable amount of treatment of organic brain disorders that is provided by psychiatrists. 

I expect that some people will say: "What is special about psychiatry? Aren't these same rationing techniques applied to all of medicine?"  To a certain extent that is true.  Primary care physicians, medical specialists, and surgical specialists have to contend with similar rationing techniques.  It is however a question of scale.  I have talked with physicians who were around when the psychiatric rationing started and psychiatric services were chosen as the target of the express purpose of elevating the stock price of a company.  I was there when the Hay Report was released in the 1990s showing disproportionate rationing of psychiatric services relative to any other specialty.  I saw the original figures released in 2002 showing that Cardiology services were reimbursed at a 20% premium, while psychiatric inpatient services were discounted by 60%.  That led to some immediate closures of psychiatric hospitals and a continued trend of lower and lower bed availability.   There are endless examples of this disproportionate rationing on this blog and as I point out in the interview it is one of many reasons I write this blog.

One of the key questions that any observer of psychiatry should ask themselves is: "Why is George Dawson the only guy writing about this issue?"  Apart from the fact that this rationing has impacted my care of patients nearly every day of my professional life there are some obvious considerations.

1.  The people who self identify as the critics of psychiatry - clearly know very little about the practice environment or its constraints. I have seen two articles now that use the same example that psychiatrists believe that every mental disorder should be treated with a medication and that this is biological psychiatry.  The model of care they are referring to is not how psychiatrists are trained (see the above figure).  It represents a blended government and managed care model of how patients are scheduled, seen, and billed.  That bureaucratic model at one point employed an M code meaning a 5-10 minute visit with a psychiatrist.

2.  The critics similarly ignore highly innovative and individualized therapies that were invented by psychiatrists such as the Assertive Community Treatment  model that I mentioned in this interview as well as the myriad ways that psychiatrists have figured out how to talk in therapeutic ways with patients in rationed time slots and how those relationships result in recovery.

3.  The critics systematically ignore the lack of infrastructure to support psychiatric treatment.  There are very few inpatient units in each state that allow for the treatment of people with severe mental illnesses. By contrast, there appears to be no shortage of state-of-the-art facilities to treat heart disease, cancer, and gastrointestinal problems.  There is no shortage of state-of-the-art surgical facilities to treat any condition where surgery may be indicated.  In the mean time, mental illness and substance use disorders are the number 1 debilitating disease condition in the United States.  Rather than invest in the necessary infrastructure to provide an equivalent level of care, people with severe mental illnesses are incarcerated instead.  Rather than reversing that trend, several Sheriffs in the country propose designated parts of county jails as psychiatric hospitals and treating people in jail who should not have been incarcerated in the first place. 

I could keep going with additional points like I have in the past, but at this point would encourage any interested reader to take a look at the interview at this link.  Then take a look at the summary at the top of this post and consider my point. Psychiatrists are well trained to do a lot for people with mental illnesses and substance use disorders. We want our patients and their families to have access to the same amount of resources that other medical or surgical specialists have. Don't accept any criticism of psychiatry that does not address these basic points.  

George Dawson, MD, DFAPA 

Reference:

Awais Aftab, MD.  The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA
Psychiatric Times.  November 13, 2020    Link

Supplementary 1:

Dr. Allen's comment made me realize a critical deficiency in my graphic and also the interview and that is impact on the academic environment. One of the most exciting aspects of medical school and residency was learning to understand the medical literature and apply it to patient care. I met hundreds of physicians and colleagues with their own unique approaches. In training environments in the 1980s and early 1990s the expectation was that you were researching and reading about your patient's problems and diagnoses and were prepared to intelligently discuss it.  As an attending you had to keep on top of the literature to be a competent teacher and also as a marker of professional competence. Teaching rounds, grand rounds and other teaching based meetings were the most exciting aspects of going to work each day.  I modified my managed care timeline to illustrate the impact on the academic side of the work environment.  

The Era of Blockbuster Drugs In Psychiatry Is Almost Over

Four years ago, I commented on a prediction that the era of “blockbuster drugs” in psychiatry would soon be over. That designation is used for medications that generate $1 billion in sales per year. Even at the time of my original comment, most of the drugs prescribed by psychiatrists were generic drugs that were often very inexpensive. The example that I frequently refer to is the antidepressant citalopram that was available for four dollars per month.

Last week PharmaCompass, a drug industry analytic and service company came out with a list of the top 100 drugs by sales in that industry. They listed the top 30 drugs by sales and their website lists the top 500 drugs with additional metrics such as whether or not sales are increasing or decreasing and by the percentage. There were no psychiatric drugs in the top 30. Lyrica or pregabalin, a drug used primarily for neuropathic pain and fibromyalgia came in at number 16 and generated $4.6 billion in sales. Some consider it to have a tertiary indication for anxiety but I would not consider it to be a drug primarily for psychiatric applications.

Sales Position	Company / Companies	Product Name	Active Ingredient	Main Therapeutic Indication	2018 Revenue in US$ billion
1	AbbVie Inc., Eisai	Humira®	Adalimumab	Autoimmune Disorder	20.47
2	Bristol Myers Squibb, Pfizer	Eliquis	Apixaban	Cardiovascular Diseases	9.87
3	Celgene	Revlimid	Lenalidomide	Oncology	9.69
4	Bristol Myers Squibb, Ono Pharmaceuticals	Opdivo	Nivolumab	Oncology	7.57
5	Amgen, Pfizer, Takeda	Enbrel	Etanercept	Immunology	7.45
6	Merck & Co.	Keytruda	Pembrolizumab	Oncology	7.17
7	Roche	Herceptin	Trastuzumab	Oncology	7.05
8	Roche	Avastin	Bevacizumab	Oncology	6.92
9	Roche	Mabthera/ Rituxan	Rituximab	Oncology, Immunology	6.82
10	Bayer, Johnson & Johnson	Xarelto	Rivaroxaban	Cardiovascular Diseases	6.58
11	Bayer, Regeneron	Eylea	Aflibercept	Ophthalmology	6.55
12	Johnson & Johnson, Merck & Co., Mitsubishi Tanabe	Remicade	Infliximab	Autoimmune Disorders	6.44
13	AbbVie, Johnson & Johnson	Imbruvica	Ibrutinib	Oncology	6.21
14	Pfizer	Prevnar 13/ Prevenar 13	Pneumococcal 7-Valent Conjugate	Vaccine	5.80
15	Johnson & Johnson, Mitsubishi Tanabe	Stelara	Ustekinumab	Immunology, Dermatology	5.25

Medications for neurological and mental disorders had a total market share of $55.8 billion or 10.2% of the entire market. There were only three medications that would qualify as blockbuster drugs and being used by significant numbers of psychiatrists and they included Latuda (lurasidone), Chantix (varenicline), and Abilify Maintena (aripiprazole).  The blockbuster drugs listed are all concentrated in a few specialties. Several are from the same class.  For example both Eliquis and Xarelto are novel oral anticoagulants (NOACs).  The total market share of the top 15 drugs greatly surpasses any amounts every attained by psychiatric medications. That makes sense because many are treating conditions that have a high prevalence and these medications generally represent an advance in pharmacotherapy.

I posted this mostly to note the trends over time. Journalists and other commentators tend to get carried away with market snapshots. I have not really noticed any negative commentary about the fact that the current blockbuster drugs that have nothing to do with psychiatric disorders are generating much more pharmaceutical company income. I also have not heard any commentary on how there is a natural fluctuation in this market based on drug discovery and the current rules on patent exclusivity. Many of the previous psychiatric “blockbusters” are obviously rapidly losing market share now that there are generic versions. I would argue that the current data also may indicate that restrictions on current medications may be limiting their market share.

The issue of direct to consumer advertising has typically not been discussed in these opinion pieces.  I have seen Rexulti frequently in television ads.  The application is generally antidepressant augmentation - accompanied by a very fast and diluted compilation of symptoms of both tardive dyskinesia and neuroleptic malignant syndrome. How much do those ads contribute to the market growth of Rexulti? My speculation is quite a lot. It would not take much for a person taking an antidepressant and not experiencing adequate relief to call their primary care physician for the addition of Rexulti.  I have seen similar ads for Vraylar.

Looking only at market share and pharmaceutical revenue only provides a look at one cost of this market. There is a huge pharmaceutical benefit manager component that generates revenue primarily by requiring their authorization for specific medications and also packaging deals for managed-care organizations. There is definite cost what they do but they currently are allowed to force physicians to work for them for free.

I hope that this information allows people take a more skeptical look at political and journalistic pieces that use pharmaceutical sales numbers and specialty sales for one rhetorical purpose for another. I am specifically referring to the recent good old days of the psychiatric drug “blockbusters” where much of what was written was an indictment against psychiatry and those psychiatrists who either worked directly for pharmaceutical companies or received some minor perk. There was the conspiracy theory that pharmaceutical companies had influenced the DSM-5.  That is both unrealistic and it greatly exaggerates the importance of that book. The data illustrates that no amount of physician manipulation can maintain a pharmaceutical product as a “blockbuster” independent of market forces.  

Those market forces also have a significant political and regulatory component where the real conflict of interest lies.  Allow me to translate that to Congress and the FDA.

George Dawson, MD, DFAPA

Graphics Credit

The top table from PharmaCompass was posted with their permission. 


Disclaimer:

I had to identify and hand count the psychiatric drugs on the PharmaCompass web site from their graphic interface.  It is possible that I missed some or the count is off (they were not numbered).  Let me know if you detect any errors.