Sunday, March 8, 2015

Psych News 1: “Diagnosisgate”

There are several recent episodes and articles related to psychiatry* that I’ve wanted to discuss, so I’m doing a short series of posts.

First, Paula Caplan has published a commentary - “Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus” - in which, drawing on David Rothman’s expert witness report in the 2010 Texas TMAP lawsuits, she calls attention to DSM-IV head Allen Frances’ financial relationship with Johnson & Johnson. Specifically, Frances and two colleagues received around a million dollars from J&J in the mid-1990s in connection with the writing of Schizophrenia Practice Guidelines favoring J&J’s “atypical antipsychotic” drug Risperdal.

The pages provided of Rothman’s report at the link above should be read by anyone interested in the many ways pharma can corrupt, but it’s this particular aspect of the TMAP story that’s of interest here:
As one of its first activities, and in disregard of professional medical ethics and principles of conflict of interest, in 1995 J&J funded a project led by three psychiatrists at three medical centers (Duke [Allen Frances], Cornell [John P. Docherty], and Columbia [David A. Kahn]) to formulate Schizophrenia Practice Guidelines. From the start, the project subverted scientific integrity, appearing to be a purely scientific venture when it was at its core, a marketing venture for Risperdal. In fact, the guidelines produced by this project would become the basis for the TMAP algorithms, giving a market edge to the J&J products in Texas. (14)

…Not only were Frances, Docherty, and Kahn ready to violate standards of conflicts of interest in mixing guideline preparation with marketing for J&J, but also in publicizing the guidelines in coordination with J&J. The three men established Expert Knowledge Systems (EKS). The purpose of this organization was to use J&J money to market the guidelines and bring financial benefits to Frances, Docherty, and Kahn. (15)
On July 3, 1996, they wrote to J&J that they were “committed to helping [J&J subsidiary] Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities” (16). Their “strategic partnership with Janssen” would help the company to “Influence state governments and providers” and “Build brand loyalty and commitment with large groups of key providers around the country”; Frances noted his concern with “how to integrate the publication and the conferences with other marketing efforts” (16). In a heading to a letter to Frances, J&J’s Director of Reimbursement Services referred to the treatment guidelines as the “RISPERDAL (risperidone) Treatment Guidelines” (16).

Caplan makes clear:
Practice guidelines are presented as state-of-the-science instructions to practitioners about how to treat people who have received a particular diagnosis. Such guidelines are considered the “gold standard” of evidence-based care because they aim to convey what is deemed to be the most reliable scientific evidence at a given time.
J&J was of course well aware of this, and “turned the guidelines into a powerful marketing tool” (17). Caplan notes that even though Rothman’s report has been publicly available, news coverage of the TMAP scandal has taken little or no note of the involvement of Frances, Docherty, and Kahn documented in the report. This is odd given Frances’ prominence in psychiatry and particularly his role as task force chair for the DSM-IV, which, with slight modifications, was in use from its publication in 1994 until the DSM-5 was published in 2013. It’s also of interest because in the past five or six years, Frances has promoted himself as something of a psychiatric renegade, challenging the scientific failings of the DSM-5 and…the influence of pharma money in psychiatry, all while presenting himself and his edition of the DSM as rigorously scientific.

Caplan describes Frances’ pattern of statements over the past several years, many of which appear highly disingenuous in light of his links to J&J. In fact, he’s always been pretty slippery and self-contradictory. But Caplan couldn’t say much that would show him in a worse light than does his own rejoinder to her at HuffPo. I won’t even bother to quote from it. Judging from the comments, his deflection and doubletalk (and sexism) are apparent to all.

The outrage over Andrew Wakefield’s vaccine quackery is fully warranted. But the silence about Frances and company, and about Joseph Biederman (for whom their work paved the way), is unacceptable. What they’ve done will harm, all told, millions of people, among them the most vulnerable – children, poor people, imprisoned people, old people.

*I haven’t written on the topic here for a few months, so if you’re new to my blog and unfamiliar with my views on psychiatric diagnosis and drugs, you can find them in my posts under the “health” tag. I explain the importance to pro-science humanists of addressing psychiatry here, and offer some reading suggestions here (to which can be added Cracked and Mad Science). In short, though, psychiatric diagnosis and psychopharmacology is a crock of shit. Their diagnoses are neither valid nor reliable, as they themselves have had to acknowledge in recent years. Psychiatric labels cause real harm, as does the biopsychiatric paradigm more generally, and psychiatric drugs – which are not medications – have hurt and killed untold numbers of people. Psychiatry should be recognized as pseudoscience, and at the very least the forcible or coercive drugging or confinement of people, especially children, should be prohibited.