One of the highlights of the American Psychiatric Association (APA) Annual Meeting is the Exhibit Hall. Here, under bright lights and fancy multimedia displays, sponsors get to show off their new wares. If anyone wonders whether modern psychiatry isn’t all about psychopharmacology, one visit to the APA Exhibit Hall would set them straight. Far and away, the biggest and glitziest displays are those of Big Pharma, promising satisfaction and success—and legions of grateful patients—for prescribing their products.
At the 2012 Annual Meeting last week, I checked out most of the Pharma exhibits, mainly just to see what was in the pipeline. (Not much, it turns out.) I didn’t partake in any of the refreshments—lest I be reported to the Feds as the recipient of a $2 cappuccino or a $4 smoothie—but still felt somewhat like an awestruck Charlie Bucket in Willie Wonka’s miraculous Chocolate Factory.
One memorable exchange was at the Nuedexta booth. Nuedexta, as readers of this blog may recall from a 2011 post, is a combination of dextromethorphan and quinidine, sold by Avanir Pharmaceuticals and approved for the treatment of “pseudobulbar affect,” or PBA. PBA is a neurological condition, found in patients with multiple sclerosis or stroke, and characterized by uncontrollable laughing and crying. While PBA can be a devastating condition, treatment options do exist. In my blog post I wrote that “a number of medications, including SSRIs like citalopram, and tricyclic antidepressants (TCAs), are effective in managing the symptoms of PBA.” One year later, Nuedexta still has not been approved by the FDA for any other indication than PBA.
In my discussion with the Avanir salesman, I asked the same question I posed to the Avanir rep one year ago: “If I had a patient in whom I suspected PBA, I’d probably refer him to his neurologist for management of that condition—so why, as a psychiatrist, would I use this medication?” The rep’s answer, delivered in that cool, convincing way that can only emerge from the salesman’s anima, was a disturbing insight into the practice of psychiatry in the 21st century:
“Well, you probably have some patients who are real trainwrecks, with ten things going on. Chances are, there might be some PBA in there, so why not try some Nuedexta and see if it makes a difference?”
I nodded, thanked him, and politely excused myself. (I also promptly tweeted about the exchange.) I don’t know if his words comprised an official Nuedexta sales pitch, but the ease with which he shared it (no wink-wink, nudge-nudge here) suggested that it has proven successful in the past. Quite frankly, it’s also somewhat ugly.
First of all, I refuse to refer to any of my patients as “trainwrecks.” Doctors and medical students sometimes use this term to refer to patients with multiple problems and who, as a result, are difficult to care for. We’ve all used it, myself included. But the more I empathize with my patients and try to understand their unique needs and wishes, the more I realize how condescending it is. (Some might refer to me as a “trainwreck,” too, given certain aspects of my past.) Furthermore, many of the patients with this label have probably—and unfortunately—earned it as a direct result of psychiatric “treatment.”
Secondly, as any good scientist will tell you, the way to figure out the inner workings of a complicated system is to take it apart and analyze its core features. If a person presents an unclear diagnostic picture, clouded by a half-dozen medications and no clear treatment goals, the best approach is to take things away and see what remains, not to add something else to the mix and “see if it makes a difference.”
Third, the words of the Avanir rep demonstrate precisely what is wrong with our modern era of biological psychopharmacology. Because the syndromes and “disorders” we treat are so vague, and because many symptoms can be found in multiple conditions—not to mention everyday life—virtually anything a patient reports could be construed as an indication for a drug, with a neurobiological mechanism to “explain” it. This is, of course, exactly what I predicted for Nuedexta when I referred to it as a “pipeline in a pill” (a phrase that originally came from Avanir’s CEO). But the same could be said for just about any drug a psychiatrist prescribes for an “emotional” or “behavioral” problem. When ordinary complaints can be explained by tenuous biological pathways, it becomes far easier to rationalize the use of a drug, regardless of whether data exist to support it.
Finally, the strategy of “throw a medication into the mix and see if it works” is far too commonplace in psychiatry. It is completely mindless and ignores any understanding of the underlying biology (if there is such a thing) of the illnesses we treat. And yet it has become an accepted treatment paradigm. Consider, for instance, the use of atypical antipsychotics in the treatment of depression. Not only have the manufacturers of Abilify and Seroquel XR never explained how a dopamine partial agonist or antagonist (respectively) might help treat depression, but look at the way they use the results of STAR*D to help promote their products. STAR*D, as you might recall, was a large-scale, multi-step study comparing multiple antidepressants which found that no single antidepressant was any better than any other. (All were pretty poor, actually.) The antipsychotic manufacturers want us to use their products not because they performed well in STAR*D (they weren’t even in STAR*D!!!) but because nothing else seemed to work very well.
If the most convincing argument we can make for a drug therapy is “well, nothing else has worked, so let’s try it,” this doesn’t bode well for the future of our field. This strategy is mindless and sloppy, not to mention potentially dangerous. It opens the floodgates for expensive and relatively unproven treatments which, in all fairness, may work in some patients, but add to the iatrogenic burden—and diagnostic confusion—of others. It also permits Pharma (and the APA’s key opinion leaders) to maintain the false promise of a neurochemical solution for the human, personal suffering of those who seek our help.
This, in my opinion, is the real “trainwreck” that awaits modern psychiatry. And only psychiatrists can keep us on the tracks.