Who's Driving the Psych Bus? [was 'Psychiatry at a crossroads']

Sen. Charles Grassley, R-Iowa

As the Times reported Friday, Senator Charles Grassley's pharma-money sweep has taken down another huge player in psychiatry: Grassley revealed that Fred Goodwin, a former NIH director who has long hosted the award-winning NPR radio show "The Infinite Mind," which frequently examined controversies about psychopharmacology, had taken in over $1.3 million consulting and speaking fees from Big Pharma between 2000 and 2007 and failed to report that income to the show's listeners and, apparently, to its producers. (For rundowns on this, see Furious Seasons, Huffington Post, WSJ's Health Blog, PsychCentraol, and PharmaLot

The expansion of Grassley's investigation into journalism throws a new kind of light on the lines through which Big Pharma seeks to shape opinion about powerful psychopharmaceuticals. And the mounting body count from Grassley's campaign -- and the fear in psych departments across the country -- adds to the sense that psychiatry stands near some sort of crisis point.

A Bit o' Background

Goodwin's reported $1.3 million in pharma income is an iceberg the tip of which was exposed in May in a Slate article by Shannon Brownlee and Jeanne Lenzer; I wrote about that article -- and about the counterattack it produced from Pharma and Infinite Mind producer Bill Lichtenstein - in an article at Columbia Journalism Review's science blog. As I noted then, Lichtenstein's counterattack, which seemed to treat failure to disclose conflicts as a hassle that is optional, ignored that drug-industry-related conflicts of interest in psychiatry have have become so big a problem that they are central and relevant to any discussion of any psychiatric disorder.

If journalists like Lichtenstein want the information they present to the public to be taken as credible, they need to err on the side of transparency, presenting not only the voices, but also the relevant financial interests of the experts they feature. Failing to do so only damages message and messenger alike. In the wake of the repeated scandals about drug-company concealment of drug-trial data, it’s strange that I have to spell this out.

Not Getting It

This same tone deafness saturated Goodwin's reported response to Grassley's revelations. If the Times quoted Goodwin accurately, he argued that he suffered no conflict of interest because the various payments from different drug companies "cancelled each other out" -- as if the only concern was whether a particular company, rather than an entire industry, might win his favor.

Goodwin's favor is well worth winning. He's enormously influential. And like Harvard's Joseph Biederman, another giant to fall to Grassley, Goodwin helped establish the notion -- a quite touchy one -- that bipolar disorder occurs in children and should be treated with powerful antipsychotics, even though those drugs frequently produce other psych problems, weight gain, and diabetes. That change in view of pediatric BPD created a 40-fold increase in its diagnosis and a corresponding explosion in prescriptions. As the Times notes, Goodwin sometimes voiced his influential opinion with a timing unsettling close to payments he received from concerned drug companies:

In a program broadcast on Sept. 20, 2005, Dr. Goodwin warned that children with biploar disorder who are left untreated could suffer brain damage, a controversial view. “But as we’ll be hearing today,” Dr. Goodwin reassured his audience, “modern treatments — mood stabilizers in particular — have been proven both safe and effective in bipolar children.”

That very day, GlaxoSmithKline paid Dr. Goodwin $2,500 to give a promotional lecture for its mood stabilizer drug, Lamictal, at the Ritz Carlton Golf Resort in Naples, Fla. Indeed, Glaxo paid Dr. Goodwin more than $329,000 that year for promoting Lamictal, records given Congressional investigators show.

Goodwin assures us that sums like $329,000 don't affect his thinking or his coverage of the company's drugs in his radio show. If he expects people to believe this, he needs to explain himself better -- for if $1.3 million doesn't swing his head, his steadiness defies both common sense and substantial research findings about the effect of gifts.

Psychiatry in a Corner

This is a deeply troubling pattern. Pharma has been shoveling money to influential psychiatrists all over the country (even up here in rinky-dink Vermont) for years now, and when the doctors get exposed they assert that even millions don't sway them. Any apologies tend to regard details of bookkeeping; more often they complain, as Goodwin did, of being persecuted for doing business as usual. No accused has yet sucked it up and questioned, much less condemned, the sort of business that has become usual. And the public stands slack-jawed in wonder, as well they might. You got paid a million-three and it didn't register?

I can see taking this stand in 2005, when the covers were first being pulled off the bed shared by Big Pharma and BIg Psych. It wasn't particularly convincing then. But it sounded less cynical than it does today. But now? Such protests today provoke the feeling that This Guy Just Doesn't Get It.

At least some of the leaders in psychiatry recognize this; some are Getting It. One prominent researcher said to me, "What I want to know is, What happened to the drug industry? It's like Hollywood. Twenty-five years ago, people went into to create something wonderful. Now it's just marketing. It's like they're selling cheeseburgers." Others have echoed this sentiment and lamented that it's extremely difficult to find non-pharmaceutical funding of biological research into psych disorders. There's some will there.

They'll need more. Psychiatry has put itself in a nasty spot,has painted itself into a nasty corner, and not necessarily because of bad intentions. The move from Freudian to biological psychiatry that began in the 1950s was spurred by the soundest of scientific impulses -- a desire to make the discipline accountable to replicable empirical evidence about physical processes rather than subjective judgments about theoretical psychic constructs. Some apparent improvement in antidepressants during the 1970s and 1980s seemed to confirm physiologically based theories like the serotonin theory; the discipline understandably got on the bus. But even as the chemical-imbalance theories failed to solidify -- and progress in related medications or insights flattened out -- the bus was found to have been hijacked. Now no one's sure how to get off without getting left behind -- and getting banged up pretty badly on landing.

How to get a well-intentioned and intellectually rich discipline back on track? If I thought I knew, I'd say. Let's hope someone figures it out soon.

Comments

[DaveD]

Bill, thanks for the comment. Regarding the issues you have with my post:

1. You say you "did not say that such disclosures were 'optional' or a 'hassle' as [I] wrote" in the post above. True, you did not use those words. But you told me and stated elsewhere that you felt it proper that the show disclose payments from industry only when you judged them clearly relevant. This is the same as saying that such disclosure is optional, since you are reserving the option to disclose or to not disclose such payments and potential conflicts of interest at your discretion. The whole point is to let the reader make the call rather than the producer or editor. This is what the scientific journals have done and what journalists need to start doing. I think Infinite Mind's need to do so was only increased by the fact that the show accepts underwriting from industry-related interests.

Your point that other media outlets have quoted Goodwin is well-taken; as my Columbia Journalism Review piece noted, journalism in general needs to face the need to ask about and state potential conflicts of interest in sources. This clearly is not getting done widely enough. We are, as you say, in an evolving journalistic environment. I also noted in the CJR that the policies you had in place when you started the Infinite Mind back in 1994 (if I that date right) seem sensible for the time -- but that I found your aggressive defense of them when the Slate piece ran this May a bit behind the times, and incognizant of how heavily such conflicts of interest have compromised public faith in psychiatry. I still feel that's the case.

[Bill Lichtenstein]

David:

As executive producer of public radio's The Infinite Mind I appreciate your story (above). It is a timely and critical look at the growing intrusion of the pharmaceutical industry into medicine and science and now directly in journalism.

That said, I have to take issue with two important points in your story.

You and I spoke back in May 2008, for your Columbia Journalism Review article following Slate.com's report that The Infinite Mind did not disclose the pharmaceutical ties of guests on a program we did examining the links between anti-depression and suicide. At the time, I did not say that such disclosures were "optional" or a "hassle" as you wrote above. According to your CJR article, what I did say was:

"...the show would not invite guests with significant conflicts of interest, and if there were a compelling reason to include someone with a vested interest, he [Bill Lichtenstein] would disclose that on air and on the show’s Web site."

In the case of the former FDA official who now does PR work for the pharmaceutical industry, Peter Pitts, who was a guest on the program without his connections being disclosed, I agreed we erred, but that NPR and PBS's News Hour had failed to learn of his connection to industry and had him on the air without disclosure as well.

Clearly, this is a problem that affects journalism in general, and a far more rigorous effort is needed for vetting and disclosing conflicts of interest in this area.

Consider that in addition to The Infinite Mind, Dr. Fred Goodwin was interviewed widely by the media as a scientific expert. As an example, he appeared in dozens of articles in the New York Times regarding the treatment of mental illness, written by respected, seasoned reporters ranging from Jane Brody to Michael Massing, where he was identified only as a researcher and academic, but without disclosure of his pharmaceutical ties. Did they know? Did they ask?

Dr. Goodwin also appeared as a guest expert discussing medication studies on various NPR programs from All Things Considered to Talk of the Nation, where NPR identified him to listeners only as a professor, public radio host, and former government official. In none of these cases did NPR make reference to any connections between Dr. Fred Goodwin and the pharmaceutical industry. NPR was in the dark, as were we.

Goodwin was not alone. Dr. Charles Nemeroff, one of the three major psychiatrists being investigated by Senator Charles Grassley for taking and not disclosing pharmaceutical fees, appeared on NPR's All Things Considered in June 2008 and previously on NPR's Morning Edition discussing research on the positive aspects of anti-depressants for children. In neither case, was his relationship to the pharmaceutical industry disclosed by NPR, and he is identified only as a "psychiatrist" and "research scientist."

Additionally, Dr. Joseph Biederman, the leading Harvard child psychiatrist who is also under investigation by Senator Grassley for not disclosing pharmaceutical consulting fees, appeared in a New York Times article on November 23, 2006, entitled "Proof is Scant on Psychiatric Drug Mix for Young." The article was written by New York Times reporter Gardiner Harris (the same Gardiner Harris who wrote the New York Times article critical of The Infinite Mind), and quoted Dr. Biederman as defending multiple psychiatric drug therapies for kids ("These drugs have revolutionized how we treat severe psychopathology in children." See: http://www.nytimes.com/2006/11/23/health/23kids.html ) However, neither Dr. Biederman's relationship to the pharmaceutical industry nor his consulting fees of at least $1.6 million between 2000 and 2007 were disclosed by Gardiner Harris in the New York Times article. (See http://www.nytimes.com/2008/11/25/health/25psych.html )

Clearly, as you point out, we are in an evolving journalistic environment. A leading Harvard clinician recently told me that he felt that pharmaceutical funding had undermined an entire generation of psychiatrists and psychiatry, as we now don't know who or what data to trust. And now it has spilled into journalism.

The proper response to the situation is not to point fingers, but to critically look at what went wrong, hold guilty parties accountable, and to look at ways of preventing it in the future.

- Bill Lichtenstein