Top Selling Drugs, Conflict-of-Interest and Market Hype

 

This post is another public service announcement to the criticism psychiatric medications in perspective. It is an essential part of the continuous production of antipsychiatry rhetoric because it must be.  If you are arguing that there are no such thing as psychiatric disorders – you do not need any treatment for them. On that basis overprescribing easily occurs because any prescribing is overprescribing. There are mixed agendas on claims that antidepressants in general cause increased number of suicides and aggressive behavior. But the most significant rhetoric has always been that there are massive conflicts of interest in psychiatry due to payments or relationships with the pharmaceutical industry. In a rare piece of special interest politics, a US Senator made these claims. Now that we have a database, it is easy to show that psychiatrists in general are not even close to the top when it comes to physician payments from the pharmaceutical and medical devices industries and in fact that most physicians have no significant conflict of interest.  This post specifically is about the top 15 selling drugs in the period 1990-2021, and where drugs typically prescribed by psychiatrists end up on that list.

I will qualify this by saying as I have many times in the past, that the only medication that psychiatrists prescribe more of than any other medical specialty is lithium.  Practically all other classes of psychiatric drugs are prescribed in greater amounts by primary care physicians, pediatricians, and an ever-increasing number of non-physician prescribers primarily nurse practitioners and physicians assistants-certified.

The methodology for this post is subject to several limitations.  First it depends on word and term frequencies counts from search engines that look at the popular, press, academic journals, newspapers, websites, and books.  By comparison the Google NGRAM search looks only at frequencies in their book collection. Algorithms are used to determine relevance and importance – but the weighting of the algorithm is not available so the actual search is a black box – but consistently applied.  It does not count word frequencies in the non-print media and in the US that would include direct to consumer advertising for many of these drugs. A second limitation is that all the counts obtained here were for the years 1990-2021 in aggregate. No curves were generated by year like the ones available in NGRAM. Sometimes a verbal estimate was available like “most of these references occurred in the past 10 years”.  A third limitation occurred when searching for terms like “antidepressant overprescribing” the search engine went from Google Scholar to Lexis-Nexis even though I had no direct access to Lexi-Nexis.  I have a request pending for that access to see if I can confirm the results listed here, especially because much of this search required an artificial intelligence search engine (Google Bard).  If I cannot get direct access to Lexis-Nexis I will attempt to check the results with a second AI search engine.

My goals were to compare the general publicity with the negative publicity of the top 15 selling medications of all time.  When I looked at that list – only one of the 15 medications was a psychiatric medication and that was olanzapine (Zyprexa). For that reason, I decided to extend the comparison to all antidepressants that were discovered during the same years (1990-2021).  During that time there was continuous criticism of psychiatrists that was primarily antidepressant based. The suggestion was that all psychiatrists were in lock step with Key Opinion Leaders (KOLs) and prescribing whatever Big Pharma wanted them to irrespective of patient need or diagnosis. This is obviously an absurd criticism but it was taken very seriously for the better part of two decades. An associated criticism was that clinical trials of psychiatric medication were permanently tainted by the same conflict of interest.  Psychiatrists were mere puppet prescribers for the pharmaceutical industry.  Like most dichotomous arguments there were vehement supporters of both poles but very little discussion of the reality that psychiatrists are the treatment providers of last resort dealing with difficult problems and they just happened to have the most expertise in prescribing these medications. These arguments also ignored the fact that psychiatrists are taught to critique literature and apply it to practice and that this life-long skill makes it doubtful that anyone prescribes a medication just based on the word of a salesman. All the attacks on monolithic psychiatry ignored what was potentially the most significant cause of antidepressant prescribing – checklist-based diagnoses popularized by managed care and electronic health record systems. No comprehensive psychiatric evaluation – just a cutoff number on a checklist. And yet no criticism of managed care companies doing this?  I have also not heard the same level of criticism for telepsychiatry services that are currently advertising their antidepressant prescription services.

 

Table 1. Top 15 gross selling medications of all time:

Medication	Sales (Kiplinger 2017)	Sales (Bard 2023)	Word Frequency References 1990-2021(1)	Overprescribing by drug references1990-2021 (1)
Lipitor (atorvastatin) 2001	$150 B	$130B	38M	20,000
Humira (adalimumab) 2008	$109 B	$240B	17M	1,000
Advair (fluticasone/salmeterol) 2000	$95.7 B	$350B	12M	1,000
Remicade (infliximab) 1998	$90.3 B	$100B	2.5M	100
Plavix (clopidogrel) 1997	$83.7 B	$55B	13M	10,000
Rituxan (rituximab) 1997	$81.6 B	$60B	1.3M	100
Enbrel (etanercept) 1998	$81.2 B	$100B	5.7M	300
Herceptin (trastuzumab) 1998	$70.5 B	$140B	1.2M	100
Avastin (bevacizumab) 2004	$67.4 B	$100B	1.5M	100
Nexium (esomeprazole) 2001	$61.8 B	$150B	7M	20,000
Lantus (insulin glargine) 2000	$61.6 B	$100B	1M	1,000
Diovan (valsartan) 2005	$60.8 B	$100B	2M	200
Zyprexa (olanzapine) 1996	$60.6 B	$55B	3.5M	1,000 10,000 for APs
Crestor (rosuvastatin) 2003	$56.9 B	$125B	1.5M	20,000
Singulair (montelukast) 1998	$47.9 B	$50B	200K	100

 

Table 2. Antidepressants approved 1989-2021

Antidepressant	Total Sales	Literature references (1)	Overprescribing by class 1990-2021 (1)
Wellbutrin (bupropion) 1985	$40B	2.5M	100,000
Prozac (fluoxetine) 1987	$32B	22M
Zoloft (sertraline) 1991	$50B	16M
Paxil (paroxetine) 1992	$40B	13M
Effexor (venlafaxine) 1993	$70B	10M
Celexa (citalopram) 1998	$50B	12M
Lexapro (escitalopram) 2002	$40B	8M
Cymbalta (duloxetine) 2004	$35B	14M
Viibryd (vilazodone) 2011	$1.5B	3M
Trintellix (vortioxetine) 2013	$2B	1M

1.  Lexis-Nexis search via Bard.

 

Table 3.  Approximate Number of Prescriptions

Drug Class	Estimated Number of Prescriptions
Statins (atorvastatin, rosuvastatin)	200M worldwide
Antidepressants (table 2 plus earlier ADs)	150M worldwide
Monoclonal Antibodies	Millions
PPIs (esomeprazole)	17.9M in 2008
Clopidogrel	18M in 2016
Valsartan	18M in 2016
Advair	2.5M worldwide
Etanercept	2.5M worldwide

 

A couple of qualifiers before comments.  First there is no organized registry or pharmacosurveillance system for basic monitoring of any prescriptions in the United States and in most countries. Total prescriptions and sales in the US have always been proprietary data.  It typically involves sampling local pharmacies and then extrapolating those sales to the larger population. Practically none of that data is available to the public but it occasionally shows up in articles in both the popular and professional press. Second, the proxies chosen here for comparing drug classes including the number of times a particular drug or term is mentioned in the popular and professional literature is also approximate because these words can be used frequently in the same paragraph and the context is not apparent – the words could be used in both positive and critical contexts. The “overprescribing” term closely paired to the drug name was chosen as a proxy for critical articles – but even then, the level of criticism and whether it was appropriate or not is an open question.  Looking at the general number of people exposed to each drug class it is reasonable to assume that 5 of the drug classes – statins, antidepressants, PPIs, clopidogrel, and valsartan have probably all been prescribed to about 200M people. The immunological drugs including the monoclonal antibodies and etanercept have been prescribed to many less probably somewhat less than 10M people. The Advair number seems very low to me since it has been around for 23 years and was able to continue patent protection beyond the expiration date not for the medication but the unique dispenser. 

I have the following observations based on what is available:

1.  Despite an overall increase in antidepressant prescriptions – new antidepressant prescribing and revenue is low.  This is probably due to the abundance of generic antidepressants and associated rationing of access to newer antidepressants by managed care companies (MCO) and pharmacy benefit managers (PBMs). My only interest in revenue is as a proxy for total number of prescriptions. Looking at the total revenue over years of availability in table 2 – antidepressants generated about $1-2B per year.

This is the downside to the antidepressant prescribing conspiracy theory.  If the business model was as simple as influencing mindless doctors there would not be such a drop in revenue.  There would be a never-ending revenue stream available just from that manipulation. The conspiracy theory fails to account for the regulatory model that rewards innovation with time limited patent protection but even then there are limits, in this case an abundance of generic drugs due to expired patent protection.

The conspiracy theory also fails to account for the fact that these patterns are well known and have happened in the past. When I was an intern one of my attendings commented that it was ironic that pharmaceutical companies were making billions off of indigestion with H-2 blockers while there was hardly any research being done on malaria - a disease that was killing a million people a year at that time. When the H-2 blockers (cimetidine, ranitidine, famotidine) became generics, proton pump inhibitors took their place in the billion-dollar profit cycle.  With the current regulatory landscape this cycle will continue to repeat.  At any given peak in the cycle it may appear there is a conspiracy to increase Pharm profits – but it appears those suggestions only happen when psychiatric medications are involved.

2.  The current top selling drugs take the approach of selling to very large populations or selling very expensive agents to smaller populations. Atorvastatin as an example generates about 3 times a much revenue per year as an antidepressant targeting about the same population size.  I have some insider information about atorvastatin and its manufacturing.  I was told by a chemist that at the time of its original manufacturing it was the most expensive tablet every produced and that cost was $1.00 per pill.  Today it is possible to get a 90 day supply of 10 mg tablets for $3.44 to $6.44 and the generic manufacturers are still making money.

3.  One of the rationales for regulatory protection of patent protection is the high cost of research.  Is there any evidence this applies to the current landscape of psychiatric medications?  At least one industry analysis expects slower than expected growth in “mental health therapies” but much greater growth in immunological therapies, cancer therapies and obesity therapy.  All would appear to be driven by current profits in these areas.  The current down cycle in psychiatric research may also explain the attempts to resuscitate hallucinogens and psychedelics for this application. There has long been the outcry that the only reason these drugs have not been adequately researched was their classification as Schedule I compounds – but the research so far has not been impressive.

4.  Given the limitations, the most striking number in the tables are the number of “antidepressant overprescribing” articles in the popular and professional literature.  That number (100K) exceeds the total number of overprescribing references in Table 1. by 25%.  There is not much granularity there but when taken in combination with statements seen in both the popular press and research literature it may confirm what has been known for a long time – psychiatry is by far the most criticized specialty whether that criticism is rational or not.

The cycles of feast and famine in the pharmaceutical industry are always the product of innovation, marketing, and politics just like any other capitalistic enterprise in the US. There is an opportunity to do immense good and we have just seen that happen with the vaccines and medications invented to stop a pandemic. Even the best possible treatments have side effects and sometimes very bad side effects. That is the expected cost of treating any diverse biological population. Psychiatrists and the medications they use are not better than that biological constraint – but they certainly are not worse.

 

George Dawson, MD, DFAPA

 

 Supplementary:  I would like nothing better than to have more accurate information about top selling drugs and who is prescribing them. If you have available sources send them to me or post the links here.  I can reanalyze the data if it becomes available. 

Graphics Credit: Many thanks to Rick Ziegler for allowing the post of his photo.

 

References:

 

1:  Brumely J. The 15 All-Time Best-Selling Prescription Drugs.  Kiplinger.  December 17, 2017

2:  Urquhart L. Top drugs and companies by sales in 2018. Nature Reviews Drug Discovery. 2019 Mar 12:NA-.

3:  Urquhart L. Top companies and drugs by sales in 2019. Nature Reviews Drug Discovery. 2020 Apr 1;19(4):228-9.

4:  Arrowsmith J. A decade of change. Nature Reviews Drug Discovery. 2012 Jan 1;11(1):17.

5:  Moorkens E, Godman B, Huys I, Hoxha I, et al. The Expiry of Humira® Market Exclusivity and the Entry of Adalimumab Biosimilars in Europe: An Overview of Pricing and National Policy Measures. Front Pharmacol. 2021 Jan 8;11:591134. doi: 10.3389/fphar.2020.591134. PMID: 33519450; PMCID: PMC7839249.

6:  Aitkin M, Kleinrock M.  Global Use of Medicines 2023: Outlook to 2027. January 2023.

 

ADHD - 28 Discussion Points

 

There was some of the usual controversy in the media today.  Is Attention Deficit~Hyperactivity Disorder over diagnosed or underdiagnosed?  The usual controversy contained the usual stories of how easy it is to get a diagnosis of ADHD in some places.  In some places it seems like just a matter of expense - a thousand dollar test battery. In other places there are people disabled by the condition who cannot get adequate treatment.  In the meantime there are international experts cranking out reams of papers on the importance of diagnosing and treating this condition in childhood. Occasionally an article shows up in the papiers about the cardiovascular safety of these medications. And in the New England Journal of Medicine there was a paper about a higher incidence of psychosis due to these medications.  Where does the reality lie?

I was fortunate enough to have worked at a substance use treatment center for about 12 years just prior to retiring. Only adults were treated at that facility. A significant number of them were diagnosed and treated as children. There were also a significant number of patients newly diagnosed as adults - some as old adults in their 60s and 70s. Whether or not ADHD can occur as a new diagnosis during adulthood is controversial and establishing a history consistent with childhood ADHD is problematic due to recall errors and biases. Secondary causes of ADHD in adults such as substance use problems and brain injuries increases in prevalence.  Although I am speculating, secondary causes seem a more likely cause of attentional symptoms in adults and therefore acquired ADHD without childhood ADHD if it does exist is an entirely different problem.

Prescribing stimulants to patients who may have stimulant use disorders is problematic for a number of reasons. Initially we had an administrative safeguard on the practice. Stimulant prescriptions could only be approved with a second opinion by another psychiatrist after reviewing the record. Eventually we had a core of psychiatrists who practiced the same way and the second opinion was no longer necessary.  Over the course of 12 years I developed these discussion points.  I think they are a good example of the minimum ground you need to cover in an evaluation for ADHD.  I typically had a 60-90 minute time frame to work with and could see people on a weekly basis for 30 minute follow ups. These evaluations were often controversial and resulted in collateral contacts, typically with a family member who was advocating for the stimulant prescription. 

A few basic points about ADHD and establishing the diagnosis. Like many psychiatric disorders there is no gold standard test.  Like some of the media discussions, I have been told that a person underwent days of testing before they were given the diagnosis of ADHD.  These are typical paper and pencil tests, but there have also been tests based on watching a computer screen and even crude EEG recordings. There are a few places that use very sophisticated brain imaging techniques. Unfortunately none of these methods can predict a clear diagnosis or safe and effective use of a medication that can reinforce its own use.  That leaves clinicians with diagnostic criteria and and a cut off based on functional status as a result of those symptoms.  That may not sound like much, but it eliminates a large pool of prospective ADHD patients who have no degree of impairment and those who are obviously interested in possible performance enhancement rather than ADHD treatment.  

Stimulant medications are highly abusable, as evidenced by several epidemics of use dating as far back as 1929. We are in the midst of a current epidemic.  For those reasons it is important not to add to the problem as either the individual or population levels. In my particular case, I was seeing patients who were all carefully screening for substance use and adequate toxicological screening. Since they voluntarily admitted themselves into a treatment center it was also more likely that they recognized the severity of the problem and were more open to treatment.  Even against that background - it is worth covering the above points.  Covering those points often involves repetition because of cognitive problems in detox or disagreement.

These are just a few health and safety considerations. My main concern in this area is that psychiatric treatments somehow have the reputation that they don't require medical attention. They are somehow isolated from the rest of the body. The person prescribing this medication needs to assess the total health status of the individual and determine if the medication prescribed is safe to use. Cardiac and neurological conditions are at the top of that list. I gave a blood pressure example because I have been impressed with how many people tell me that their blood pressure was not checked after a stimulant prescription or a stimulant was started despite diagnoses of uncontrolled hypertension, cardiovascular disease, cardiac arrhythmias or cerebrovascular disease.  These were typically new prescriptions in older adults with no prior history of ADHD.  

Coexisting psychiatric disorders are also problematic. Most have associated cognitive symptoms if they are inadequately treated. That is not a reason to diagnose ADHD or start a stimulant medication.  Typical symptoms that can be caused by stimulants are have to be recognized and the medication must be stopped if adjusting the dose is not helpful.

It is important to keep the range of biological heterogeneity in mind. Once you have narrowed down a population of people who most likely have ADHD, they will not all have a uniform response to medication.  They may not all want to take medication.  As adults many stopped taking ADHD medication and adapted to a work and lifestyle that works very well for them. That is a very suitable outcome for an initial assessment.  There is another group who want to try a verbal therapy for ADHD in some cases because they recognize they can no longer take stimulants because they were escalating the dose. That is also a suitable outcome for the assessment. In those people who have ADHD are want to take a medication, I think a non-stimulant medication like atomoxetine is a good place to start. In my experience it works very well.  Disagreement about stimulants, especially in people with a stimulant use disorder typically requires extended conversations with the patient and their family. A quality control initiative can provide very useful data for that conversation. I suggest that any clinic or clinician who prescribes stimulants collect outcome data on those prescriptions.  The key piece of data is a comparison of the relapse rate of those patients taking stimulants compared with patients treated with non-stimulants. Other data could be collected as well - like how long the prescriptions were refilled. There are rules about collecting that data depending on your practice setting.  Check those rules first.  Outcome data will be the best data on whether a correct decision was made about prescribing the stimulant.

I added the following slide based on polypharmacy considerations in the paper cited in reference 1.  This is a common clinical problem that needs to be approached rationally and that includes limit setting on the concept that every side effect or symptom needs to be addressed by a medication rather than a medication discontinuation, reduction, or substitution.  I always include a discussion of rare but serious side effects, synergistic side effects, drug interactions, interactions with comorbid medical problems and associated medications, and very serious interactions that could lead to hospitalization or death, like serotonin syndrome. 

I am going to end on a note about countertransference based on a disagreement I had at a conference about my methods. The speaker advocated for prescribing stimulants as a general operating practice for anyone with ADHD. When I confronted him about the problem of substance use he claimed his motivation was that he considered it his priority to "help" people and he thought that stimulants were the most helpful medication.

Whether or not a medication is helpful for any psychiatric disorder depends on a very careful assessment and clinical expertise that considers several dimensions including the potential risks and benefits for the patient and the incorporation of the patient preferences and values into the clinical decision making process.  In my evaluations, I try to sum all of that up in an informed consent discussion. In the area of ADHD evaluation and treatment, that covers a lot of ground and there is no simple uniform recommendation.

George Dawson, MD, DFAPA

Photo Credit:  Many thanks to my colleague Eduardo A. Colon, MD for allowing me to use his photos. 

The Semi-Random Pathway To A Psychiatrist

 

Mischaracterizations about how people come to see psychiatrists are an ongoing phenomenon in the media. It is one of many false premises used to build the idea that there is a monolithic psychiatry out there that is really an evil empire. That stands in contrast to psychiatrists going to work every day and seeing a full schedule of patients that was compiled without their knowledge or input. I will try to explain what really happens in this post.  My explanation is complicated by very little research done on this topic.

In my experience and the experience of the colleagues I have worked with, it is rare for a person with mental health problems to be seen by a psychiatrist without previously having seen another physician or mental health professional. That is true for both emergent and elective situations.  It follows that those patients have also been treated with medications and psychotherapy, often many different medications from different classes and different forms of psychotherapy.  The period of treatment before seeing a psychiatrist is typically quite long. As an example, in my last job as a consultant at a large substance use treatment facility – I was seeing people in their 30s and 40s who had an onset of a psychiatric disorder in their teenage years, gone through various treatments, and were seeing me as the first psychiatrist they had seen in their life. That could have been as long as 5-6 years of illness onset with no treatment followed by another 10-20 years of ineffective or sporadic treatment.

This is a hard problem to delineate because of all the factors involved. There may be a preference to not see a psychiatrist because of the connotation that psychiatry is equated with a more serious illness or the misconceptions about psychiatry that are actively promulgated by special interests. In some cases, primary care physicians consider themselves to be the right person to manage anxiety or depression.  The recent collaborative care initiative and physician rather than patient-based consultation may reinforce that idea. I have seen patients who were in treatment with every possible alternative medicine practitioner and getting treatments that could either not possibly help them or in some cases were detrimental. Some of my patients were in cults who claimed to be helping them until they were rescued by family members and brought to psychiatric treatment. Self help is a popular approach and some of it is very good but in other cases it can also be detrimental.  When bibliotherapy is used, the advice often includes instructions on sleep, diet, and exercise.  Many people resort to self-diagnosis and self-medication. Supplements are generally expensive and ineffective. Alcohol, stimulants, cannabis, benzodiazepines, psychedelics, and other intoxicants are uniformly ineffective and often amplify the original problem or create new problems.

In some cases, the person already has a very healthy lifestyle and given popular recommendations it is tempting to just amplify the health factors.  More protein, more sleep, and more exercise. It is very doubtful that any of those factors alone or in combination will address a serious mental health diagnosis.  I have treated world class athletes in the top 1% of all exercisers who got no relief at all from exercise.

Insurance limitations and rationing has been a significant factor in the last 40 years. A study done showed that referrals from managed care companies seldom result in real appointments with psychiatrists – in many cases because the insurance company claims that psychiatrists are in their network when they are not.  These are ghost networks or phantom panels (1).

Practice setting is also an important factor. During my 22 years of acute inpatient care – all of the people I saw were either taken to the emergency department or presented there themselves.  Most were untreated for years.  Some were overtreated with medication combinations and were seeing me because of side effects. It was more likely they had seen a psychiatrist because we had an outpatient department and our colleagues’ patients were hospitalized, but reviewing those histories it was clear they had been untreated for years before being seen in the outpatient department.

I first learned about the importance of the pathway to physician care in medical school.  When you first start seeing patients, there is an excessive focus on the form of the medical evaluation rather than the phenomenology. In other words – you want to carefully document all the history, symptoms, and findings that lead to a diagnosis and treatment plan. You are under the mistaken assumption that is all there is to being a physician.  At least until your first attending asks: “Well – what is the reason this patient sought treatment at this time? Why did they decide to come into the emergency room right now?”  At that point you start to realize that there are not a set number of pathways to care and patient presentations – there are millions.  Your job is to describe that unique pathway for every individual patient that you see – no matter what the problem is.

The pathway to psychiatric care in the United States is semi-random. People rarely make a conscious decision to see a particular psychiatrist and then see that person. At some level psychiatrists are the treatment providers of last resort and you are likely to see one in an emergency that you never planned or when another treatment provider tells you that it might be a good idea.  It is likely that a lot of disability and distress occurs in the meantime, along with a lot of bad advice. I think it is reasonable to try self help and other qualified mental health professionals first.  But if you are not seeing any good results – I would not let it go on for too long.  Like most things – if what you read in the papers about how a certain treatment for your problem seems too good – it probably is.

George Dawson, MD, DFAPA

Supplementary 1: 

Here is a post from about a year ago on involuntary treatment.  Look at the diagrams to see the number of personnel and steps involved in the process - apart from the psychiatrist. In a hospital setting - activating the civil commitment process typically occurs when an emergency department doctor or hospitalist places the person on an emergency hold.  In some states only police officers can initiate an emergency hold and in others any interested person.  An entire series of decisions not made by any psychiatrist determines if that person is eventually held or released.

Supplementary 2:

This is a graphic that I made from another application showing some alternate pathways to psychiatric treatment.  In almost all cases there is no psychiatric contact until the tier of treatments designated by white and green rectangles and possibly in the team approaches.

References:

1:  Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three U.S. cities. Psychiatr Serv. 2015 Jan 1;66(1):94-6. doi: 10.1176/appi.ps.201400051. Epub 2014 Oct 31. PMID: 25322445.

 

Everything You Wanted To Know About Psychiatry In 30 minutes or Less....

 

It has been a week since I gave a presentation to the Philolectian Society in Anoka, Minnesota.  The Philolectians are primarily retired educators and their colleagues who decided they wanted to promote education in their county. They do this by topical discussions on a monthly basis and fund raising for scholarships that they award to high school students.  They were founded 134 years ago.  I gave them a presentation on substance use disorders about 5 years ago – but my current presentation was entitled “Everything You Wanted To Know About Psychiatry In 30 Minutes of Less.”  It was the mile high view – but that is the one that is typically lacking in American culture.

The venue was a sports bar conference room in an old building. There was no projection equipment and it had spotty WiFi coverage so I decided I should test it out ahead of time. I opted to use a Chromecast device to the television HDMI port – but did not realize at the time that it does require WiFi in order to work.  Connection to my home TVs was not a problem but there is continuous WiFi as the background.  Failing the Chromecast, I was given an LED projector that also required WiFi. I ended up printing out hand outs for the attendees. The 12 slides follow and total time was about 45 minutes – 30 minutes of presentation and a 15 minute Q & A.  My presentation style is to focus on slide design.  For that reason I avoid the standard templates and try to cover as much of the slide with graphics as possible when they are used.  My second overall principle is to free associate to the slides and never read them. They are there to keep me on track.  What I actually end up saying varies considerably from lecture to lecture – modifiable by various factors including what the group has indicated what they want to hear, what I have been thinking about that day, and what I have been reding that week. The process is like Frank Zappa described his guitar playing. Every live performance is unique – no set of notes is identical.  I can’t claim mastering lectures like he mastered the guitar but there is some creative process involved in lecturing.

The title slide uses a background of abstract art taken off of one of my paintings at home. The artist is Stephen Capiz.  It represents a very small area of a larger abstract painting with the tile information superimposed. The title was chosen to keep the atmosphere casual. I wanted people to be comfortable that this was not a presentation to mental health professionals but to a general audience.

Slide number 2 is a critical three - fold message that is frequently missed or distorted.  Psychiatric disorders have been observed and discussed since ancient times.  That means they are easily recognizable to people with no training. It means that they are real and can’t be explained away.  You must be incredibly naïve or sheltered to not have that experience.  Psychiatrists only exist because they were the doctors interested in treating these disorders. That is as true today as it was in the 18^th and 19^th century.  The only difference is that modern psychiatrists have uniform training. And finally as you would expect, the diagnostic system has undergone successive refinement over the centuries.  The DSM is used as an example here but the ICD could be used as well. (with all slides click on them to expand and get a better quality graphic - this is apparently an artifact of the blogger format).

 

Slide 3  provides a little more detail on the evolution of the DSM systems. Counting the total diagnoses is always a point for rhetorical digressions.  I finally figured out how to do it and listed my specific technique in this post.  To a professional audience, I might include studies on how many of the diagnoses are actually used.  This audience did not find any of this controversial.

Slide 4 is a great timeline of how psychiatry developed from a discipline that Kendler refers to as protopsychiatry to the modern era starting in about 1920 in the US and about 40 years earlier in Europe.  The audience was extremely interested in the low percentage of physicians attending medical schools in 1900 and that lectures could be attended by purchasing tickets. The transition from asylum doctors with no particular training to psychiatrists was also a focal point.

Slide 5 was necessary because there is still a lot of emphasis on Freud. I remembered that Freud was an important figure to my college English professors and that some of the teachers in the audience were about that age. I emphasized that Freud was an important figure in psychoanalysis, but that there were many European psychiatrists that provided knowledge, literature, and training to their American counterparts and that many were self-taught and active across the fields of psychiatry, neurology, neuropathology, and neuropsychiatry.

Slide 6 is a very brief outline of the basic educational milestones of the various mental health disciplines.  Minnesota has a confusing array of designations including unlicensed mental health practitioners so I kept it simple.  In the previous slide on the psychiatry timeline I did mention how in the early 20^th century most practitioners considered themselves neuropsychiatrists and practiced both neurology and psychiatry. When the American board of Psychiatry and Neurology informed practitioners that they would need to take board exams in both psychiatry and neurology the era of separate specialties was begun.

Slide 7 is one of my favorite graphics.  It is produced from the current educational requirements for residency training and Melissa Farmer, PhD greatly assisted me with the graphic design. My overall emphasis was to point out how these training requirements should result in a physician who is not only an expert in diagnosis, but also interviewing, maintaining relationships over time, and capable of therapeutic discussions.

Slide 8 attempts to capture the pattern matching aspects of psychiatric practice and why training and experience are necessary.  It illustrates how previous exposure to various diagnostic and therapeutic elements can lead to problem recognition and resolution.

Slide 9 is a rough sketch of the diagnostic process and how it has to be adapted to the situation.  I provided several examples of referrals that I saw as referrals who needed immediate emergency medical attention.  We discussed how that can occur.

Slide 10 is a list of psychiatric subspeciality care.

Slide 11 is an explanation of the current workforce and how the practice environment has deteriorated over the past 40 years. I emphasized rationing as the main problem and several audience members were aware of the shortage of psychiatric beds and state hospital closures.  The city of Anoka has one of the few remaining state hospitals – Anoka Metro Regional Treatment Center. In the future if I am projecting - this slide would be split to 2 separate slides. 

Slide 12 – I had to leave the audience with a reason why they are exposed to antipsychiatry rhetoric and discussed the basis for it, the special interests involved, and in most cases - the lack of any basis in reality.

The presentation went very well. There was additional interest in the medical and psychiatric effects of the pandemic.  Several audience members were interested in my opinions about the Department of Human Services in Minnesota and how they factor into the current rationed system of care. I am currently expanding some of the graphics in case there is any additional interest and as an outline for some of my other writing.

 

George Dawson, MD, DFAPA

A Confluence of Factors - Why There Is No Functional System of Care for Severe Mental Illnesses

 

 This post was stimulated by a confluence of factors.  I had no real concerns about what I would do in retirement and it seems that I have as much to think about as I did when I was working.  The factors included:

1.  A post by one of my esteemed colleagues on Twitter – Emily Deans, MD.  I have never met Dr. Deans and know her work primarily through her blog, Substack, and Twitter posts.  I cannot recall ever disagreeing with her.  Today she began a thread with: “The US allows people with terrible brain illnesses to languish on the streets and get murdered on the subway.”  She built upon that theme.

2.  I was working on a presentation for Friday May 5 on “Everything You Wanted To Know About Psychiatry in 30 Minutes or Less.”  That got me into a historical frame of mind.

3.  I had the occasion to pick up my copy of Sylvia Nassar’s biography of John Nash “A Beautiful Mind” and reread the description of his civil commitment to a state hospital where he received insulin shock treatments at age 33.

4.  During my work on the presentation I suddenly got the bright idea to create a couple of new timeline graphics – one of which was about European influences on American psychiatry (protopsychiatrists, transitional self-taught psychiatrists, and psychiatrists) and that led to thinking about the current state of psychiatric affairs in the United States.

That all came together to produce the following paragraphs that I have discussed here before but seems reinforced by the current confluence of information.

Psychiatric care in the US is abysmal and it is not due to the lack of bright and highly motivated psychiatrists.  It is due to a lack of access.  It is possible to find those psychiatrists and get treatment but good luck with that.  Dr. Deans is correct that people are currently dying due to the lack of humane laws to treat people with severe mental illnesses. In many jurisdictions those laws are interpreted in the context of the lack of resources.  In other words if there are no facilities available, legal action is dropped. That problem lies squarely on several entities that are far outside of psychiatry. The problem is so chronic it is hard to prioritize which of these entities came first and is the worst (although I have provided a few timelines). Let me take them point by point as they come to mind.

The antipsychiatry movement needs to finally get credit for its destructive nature. Psychiatrists tend to respond either by ignoring them and hoping they will go away or by wasting their time trying to argue against their repetitive rhetoric.  The pandemic and the last election highlighted the use of misinformation in social media. The antipsychiatry movement are experts in misinformation and they have been using the same tactics for the past 50 years.  Part of those tactics include getting their rhetoric and opinions in the mainstream psychiatric literature. In 1986, Martin Roth and Jerome Kroll had the following observation:

“We have argued in this section that the concept of mental illness has definable boundaries and that medical forms of care are appropriate and efficacious only in circumscribable portions of those who present a danger to society. But recent trends if allowed to continue, can only culminate in a society in which prisons again contain a large portion of those who suffer from mental illness because there is no appropriate or alternate form of care or accommodation for them. If such a situation should materialize, the distinction between prison and hospital will become once again blurred and obliterated like it was 133 years ago when Bucknill held out optimistic hopes of a new era in which science and humanity would jointly seek to surmount the problems presented by morbid mental suffering. The hard-won and remarkable progress achieved by psychiatry during the past half century in particular, will then have been set into reverse.” (p. 114).

There has not been a more prophetic statement in the field.  The largest psychiatric hospitals in the United States are currently county jails. The state hospital systems that were in some cases flagships for treatment of people with severe mental illnesses are no longer functional and exist at the margins to alleviate pressure on community hospitals to accept involuntary patients.  It is more of a blockade than a bottleneck since the latter would suggest movement once the obstacles have been passed.  There is no movement and the association of state mental health directors has made it very clear they are not interested in movement.

The basic paradox of the system is that the necessary infrastructure necessary to treat even average numbers of persons with severe mental illnesses and those who are under civil commitment is not there.  It is atrophied or rotten and there has been no wide sustained effort to improve it since The Community Mental Health Act of 1963. Even though the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 – it is clear to anyone working in the field that there is no enforcement to ensure mental health parity or adequate substance use treatment. The healthcare industry has sent a clear message that it takes more than a law on the books – it takes concerted and very expensive legal action.  In the past some activist attorney generals had some success – but there are not many of them around anymore.

It is not hard to imagine how a fragmented system of care has withered during a time of continuous antipsychiatry rhetoric.  Money is always cited as a limiting factor, but the amount of money especially compared with the ballooning number of administrators at the state and health plan levels does not seem great. State hospitals and departments of human services seem to run on a managed care rationing model rather than a model focused on helping the most vulnerable citizens. It is not a coincidence that both antipsychiatry and business rationing for profit both depend on Libertarian values – the most basic being “you are only worthwhile if you are living what I determine to be a worthwhile life.”  That same value system criminalizes aggression and violence secondary to mental illness and sees incarceration as the only beneficial outcome. That is consistent with the current model of county jails as psychiatric hospitals that do not deliver any psychiatric care.

That brings me to the Nash biography. He was hospitalized in about 1961 at Trenton State Hospital.  According to Harcourt’s graphs of deinstitutionalization – this was the beginning of a time of rapid decline in mental hospitalization rates that has continued unabated to the present time. Trenton was overwhelmed by the large number of patients seeking help there – 4,000 after World War II dropping and then rising again in the 1960s to about 2,500 when Nash was there. Psychiatrist staffing ratios varied from 1:100 patients in the acute ward to 1:500 patients in the chronic ward.  Length of stay for most patients was about 3 months. Rationing clearly existed even before deinstitutionalization. One of the psychiatrists who worked there described the environment as “crummy.”  In terms of personal relationships with patients – it could be expected to be rare with those staffing ratios.  Nasar describes the hospital as “overcrowded, underfunded, and understaffed.”

Figure 1. Rates of Institutionalization in Mental Institutions and State and Federal Prisons (per 100,00 adults) from the paper by Bernard E. Harcourt, " REDUCING MASS INCARCERATION: LESSONS FROM THE DEINSTITUTIONALIZATION OF MENTAL HOSPITALS IN THE 1960s," 9 Ohio St. J. Crim. L. 53 (2011), available at: https://scholarship.law.columbia.edu/faculty_scholarship/639

The exception noted was the insulin unit.  Apparently, Nash was recommended to go to this hospital because it had this modality.  It was a 44-bed unit – half men and half women in separate wards. Patients on that unit received special diets and special recreation.  That is where Nash got insulin treatments 5 days a week for the next 6 weeks. Nash later described the agony of these treatments in detail including what may have been long tern effects on his dietary pattern.  In retrospect, the question is whether it was necessary or not.

Manfred Sakel had discovered insulin shock treatments (IST) in 1935 by accidentally administering too much insulin to a patient with morphine addiction resulting in seizures and a coma.  The patient awoke with more mental clarity.  That led to further trials and wider application. Nassar suggests that by 1960, IST had been phased out in most hospitals and replaced with electroconvulsive therapy (ECT).  Max Fink did a direct study of chlorpromazine versus IST in 1958 (2) and noted that the results clearly favored chlorpromazine.  That resulted in the IST unit at his hospital closing within 6 months (3). Even though Nash had not been able to work for the previous 3 years he was widely regarded and his intelligence was described as a national security asset. As he was recovering, he started a paper on fluid dynamics while he was at Trenton that he subsequently finished and published in 1962 French mathematical journal. He was awarded the Noble Prize in economics for game theory in 1994. His original two page paper at age 22, was part of the basis for the Nobel determination (5,6).    

Nash’s tenure at Trenton is a good example of rationing prior to managed care. The rationing resulted in both the abysmal conditions and a lack of state-of-the-art care. Some might say that you can’t argue with results.  Nash recovered and was able to go back to research and publishing in mathematics, despite his dissatisfaction with treatment.  Later in his biography he was treated with a number of second generation antipsychotic medications that were described as helping him stay out of the hospital but  “have not given him a life.”

That brings me back to Dr. Dean’s comment at the top of this post. We have people with severe mental illness dying on the streets. A small number become aggressive and violent, but a much greater number are victims of violence and exploitation. They do not have stable living situations and there are associated problems with substance use disorders. This is a gross level of neglect compared with way other healthcare problems are addressed requiring more resources than psychiatric care. About 1 in 300 people get retinal detachments during their lifetime. In any mid-sized city in the United States access to state-of-the-art retinal care is not a problem. The same thing is true for orthopedics, gastroenterology, and cardiology. Psychiatric care is fragmented across private pay systems, public pay systems, and managed care systems.  The last two are managed by large bodies of administrators that are focused on rationing rather than an adequate system of care. In many ways, the landscape of psychiatric care is approached with the same level of recklessness as firearms. We all have to pretend that something useful can never be done and therefore maintain the status quo.

 

George Dawson, MD, DFAPA

 

References:

1:  Roth M, Kroll J.  The Reality of Mental Illness.  Cambridge University Press. Cambridge, England 1986: 82-144.

2:  Fink M, Shaw R, Gross GE, Coleman FS. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. doi: 10.1001/jama.1958.02990150042009. PMID: 13525160.

3:  Fink M. Meduna and the origins of convulsive therapy. Am J Psychiatry. 1984 Sep;141(9):1034-41. doi: 10.1176/ajp.141.9.1034. PMID: 6147103.

4:  John F. Nash Jr. – Facts. NobelPrize.org. Nobel Prize Outreach AB 2023. Sun. 7 May 2023. https://www.nobelprize.org/prizes/economic-sciences/1994/nash/facts/

5:  Holt CA, Roth AE.  The Nash equilibrium: A perspective.  PNAS. 2004; 101 (12) 3999-4002.  https://www.pnas.org/doi/10.1073/pnas.0308738101

6:  Nash Jr JF. Equilibrium points in n-person games. PNAS. 1950 Jan;36(1):48-9. https://www.pnas.org/doi/full/10.1073/pnas.36.1.48

Graphic Credit:

I took this photo of the Rum River Dam in Anoka, MN about 30 minutes after I gave my presentation on May 5, 2023.  Anoka happens to be where the Anoka Metro Regional Treatment Center is located.  It is the last state mental hospital in Minnesota.  Since 1978 Minnesota has closed 10 of its 11 state hospitals and only AMRTC remains.  There have opened 6 - 16 bed units called  Community Behavioral Health Hospitals that have reduced capacity and apparently do not accept referrals from major metropolitan hospitals. https://mn.gov/dhs/people-we-serve/adults/services/direct-care-treatment/programs-services/community-behavioral-health-hospitals/