Editorial Note: This is the third part of a talk giving to the BNPA on February 22. It follows on from Tweeting While Psychiatry Burns and Tweeting While Medicine Burns. The final group of slides are HERE.
The talk you have just heard was first given in Toronto on Thursday November 30 2000 to mark the 75 anniversary of the University Dept and 150 anniversary of the Queen Street Mental Hospital (Slide 1). The Chads were still hanging in Florida while the Supreme Court tried to decide whether Bush or Gore had won.
I had recently been hired by the University of Toronto and I and a number of others had been invited to contribute to a meeting to celebrate the occasions.
I led off the program with the talk pretty much as you’ve heard it. The word for word original is HERE.
One of the other speakers was this dude – Charles Nemeroff. Nemeroff was quite happy at this point in time to be featured as the Boss of Bosses (Slide 2). He wasn’t the boss of bosses because of any scientific or clinical contribution of which there was none.
In line with these Mafia connotations, at the meeting Nemeroff approached one of the key people involved in my hiring and suggested they get rid of Healy. According to Nemeroff later, this individual wet his pants. The University later claimed my colleagues were disturbed by the talk and would have found it difficult to work with me. They also claimed Healy had said Antidepressants cause Suicide which was like crying Fire in a crowded theater.
The talk was as you’ve heard it. It was a talk about lack of access to data not about antidepressants and suicide. It was the plot of a book then in press – The Creation of Psychopharmacology (Slide 3). Harvard University Press don’t do wild or off the wall.
My talk received the highest rating on the day by the audience which seems at odds with later university claims. Nemeroff was the lowest (Slide 4). His talk was largely an advert for paroxetine (Paxil – Seroxat) and how it was more of an SNRI than people thought which didn’t seem particularly appropriate for the occasion, but perhaps interesting in that he seemed to be thinking about being an expert for GSK in the forthcoming Tobin trial.
Escape to New York
Nemeroff flew to New York that Thursday night. The following morning, Friday, at a Suicide Prevention meeting he told colleagues that Healy had lost his job.
Unaware of any of this, I flew to New York on Friday morning and that afternoon was a few blocks away from Nemeroff. Neither he nor I knew this. I was in Pfizer’s archives where even the loo paper was marked confidential. Articles in the public domain for years were stamped confidential.
But extraordinarily this document wasn’t (Slide 5). This page comes from a portfolio of articles on Pfizer’s Zoloft. covering the writing of articles on Zoloft for ingrown toenails, for anxiety, for the elderly, for the young and how it was cheaper than older treatments that cost only a fraction of its price. This page shows you that there were two articles on PTSD being ghostwritten for leading journals. The articles were written, the journals selected, the company just had to decide on who the authors were going to be. TBD stands for To Be Determined.
Based on this portfolio of articles we were later able to show that heading toward 100% of articles in the peer reviewed literature on on-patent drugs are ghostwritten. In 100% of cases there is lack of access to the data. This is true across medicine. It applies to respiratory, neurology and cardiac medicine as much as to psychiatry.
What it means is that for instance the NICE guidelines which are based on these articles are Junk. Complete and utter junk. But increasingly our trainees and everyone else are trapped by Guidelines like these. We will lose our jobs if we don’t adhere to them. This is what has led to the opioid epidemic in the US.
A few days after I gave this talk, I was informed that I had lost my job – I wasn’t a good fit and the department would lose money.
Over the last sixteen years when visiting the US, I have been struck at what can only be called a Medical McCathyism. Everyone in healthcare is scared to open their mouths. While the average American is probably still prepared to stand up for themselves than the average European, when it comes to doctors at times it feels like the land of the craven and the home of the slave. Just last week, however, the President of Royal College of Surgeons in Britain made a case that medicine in Britain is heading exactly the same way.
Pretty soon after this talk, the worry has to be most of us in the US, UK and Europe are going to lose our jobs – at least going to lose the kind of jobs many of us thought we were taking up when we entered the field.
If the drugs are as effective as we are told and as free from side effects as we are told, you can replace high cost prescribers with nurses, pharmacists and pretty soon with robots. This is in fact happening quite rapidly.
In the 16 years from 1952 to 1968 the world changed in astonishing ways. In the 16 years since I first gave this talk, it seems to have changed almost as much again.
So when some future historian in a very few years from now, looks back at this period and wonders about the senior figures in the field – the Jean Delays (Slide 6) – in the UK they will have Sir before their name – will say they say it was a time when the field’s significant figures tweeted while psychiatry burned?
The slides here changed from the original 2000 slides at two points. The weighing scales slide is now in color. In 2000 it was black and white. And the Risk Hammer now replaces a Hamburger – hamburgers were scary images in 2000 with BSE.
The original words are HERE.
Later on Monday, the day of posting, Barney Carroll emailed this comment and the article that goes with the photo of the Boss.
I stumbled upon this photograph on Twitter today, courtesy of David Healy. It’s a pair with the classic fawning article about Nemeroff, which I will attach as well. The article is written by James LaRossa who bought the rights to Psychopharmacology Bulletin in the mid to late 1990s and then hired Nemeroff to turn it into a vehicle for infomercials. These bring back such fine memories!
Boss of Bosses Charles B Nemeroff, MD, PhD
Charlie Nemeroff is sitting quietly at the speaker’s table, ignoring the bustle going on around him. His face betrays nothing – neither boredom, nor interest, or apprehension. Only the blinking of his eyes distinguish him from a statue. When he hears his name he rises very slowly, and begins to move to the lectern with deliberate strides, gathering speed as he goes, brightening now. He breaks into a grin and begins speaking the minute he approaches the microphone and, before the hush of the room takes hold, he has won the crowd with a disarming and deliberate manner that cuts simply to the heart of the most complex issues in neuropsychiatry.
Charles B Nemeroff, MD, PhD, chairman of the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine in Atlanta, finds himself addressing a room of crowded colleagues hundreds of times each year. Even in the ultra-competitive world of medicine and academia, Nemeroff is admittedly the most coveted academic speaker in psychiatry in the United States. His prolific authorship (he has published 600 research reports and reviews) along with a sheer enormity of research grants, awards, and scientific board appointments, has afforded him unprecedented celebrity within the psychiatric community.
Nemeroff’s academic and intellectual largess translates to a small and influential group of close friends, including fellow department chairmen Alan Schatzberg (Stanford), Marty Keller (Brown), Dwight Evans (U. Penn), Bob Hirschfeld (U. of Texas, Galveston) and NIMH heavyweight Dennis Charney, all of whom spend a great deal of professional and personal time together. Psychiatry is a highly charged topic these days, and these six thought leaders walk a fine line between controversy and political correctness, often made possible by their strong allegiances both to topics and to one another.
The ethics surrounding the implementation of placebo-control trials is one of psychiatry’s most supercharged political issues, as is addressed in more detail in this issue of TEN. “From a scientific point of view, the best data on efficacy of any treatment is best derived from placebo-controlled trials,” Nemeroff says. But with diseases like cancer and stroke, placebo trials become unethical. Thus, “the FDA in most cases has allowed for comparison between novel treatments for devastating disorders with traditional already-approved treatments.” If a novel agent proves efficacious against an existing agent, it gets approved. But “that has not been the case in psychiatry. And we have to raise questions about the use of placebo in conditions like mania, where patients are terribly ill. [In these cases] one wonders why it isn’t sufficient to have evaluation based on ‘just-as-good-as’ or ‘better-than’ currently available treatments and better side effect profile.”
Nemeroff is among the most coveted advisors to the pharmaceutical industry. Predictably, rumors about his alliances, or lack thereof, abound. It is safe to say that his views are expressed in a forceful manner he is a passionate person and he fully expects to lead the corporate strategy of those he advises. Those who do not heed his advice are often recipients of his wrath. Consequently, Nemeroff is often in favor with the most successful drug makers, since those firms are doing the lion’s share of research, which he often directs.
Privately, Nemeroff is circumspect about the role between private and public funding. Working with industry can “be a win-win. There is a shared vision but also separate mission. The university mission is a troika: research, teaching, clinical service; whereas the pharmaceutical industry [mission is to] discover new drugs and to market them effectively. Sometimes those goals are simpatico and sometimes they’re not.” As an example of a situation where industry funding works to the benefit of the scientific community, Nemeroff recounts a new teaching council that he started recently with a grant from Janssen called The Young Faculty Development Program, where young professors get the opportunity to learn about clinical issues and academic life. And he talks also about the differences he sees between today’s young clinicians and those of his generation. ”In the past, there was a clear schism between psychoanalytically oriented psychiatrists and so-called biological psychiatrists. Today, this mindframe dualism seems silly… Patients of course have both minds and brains.” The fact of the matter is that psychosocial factors… can certainly affect how the brain functions and we also know that the brain itself changes. The nature/nurture controversy is really no controversy, as we’ve improved our understanding of the brain.”
The Bronx-NY-born Nemeroff is most content being both a researcher and a physician. As an example, he recounts a part of the very day of this phone interview. “[Earlier today] I saw four patients, one on emergency consult; at the same time, I was dealing with a number of issues related to an NIMH grant of the psychobiology of early trauma. What can be better than being a teacher and a researcher and a physician?”
James La Rossa Jr. & Genevieve Romano