I have been watching, and sometimes writing about it here, the cascade of revelations about unreported money, withheld research, and other disturbing issues within psychiatry. The disclosure last week that Charles Nemeroff, one of the major figures in psychiatry today, had lied about how much money he received from drug companies -- a whole lot -- seemed to be a tipping point of some kind. Because since then there have been articles and editorials questioning ethics and the place of greed in this whole mess. Judith Warner of the NY Times wrote about greed. Friday, the Times weighed in with an editorial. Critical bloggers likewise -- Furious Seasons, CP&P, Carlat -- have written about this issue and eloquently. If you haven't already, I urge you to read them.
The Times editorial concludes:
"The tactics included delaying publication of studies that found no evidence that the drug worked for some disorders, spinning negative data to make it look more positive and bundling negative data with positive findings to neutralize the results. Pfizer denies any such manipulation. It will be up to the courts to pass final judgment on what looks like tawdry behavior."
This is far more than tawdry behavior. That there has been manipulation of data and results on research conducted by investigators who cannot be unbiased seems to me to cast in doubt a great deal of what has been touted as truth in the field over the last several years.
Americans seem especially fond of research evidence to support behavior. We like it when there are studies to cite to explain what we choose to do. So we have the vast number of people who talk about their "chemical imbalance" to explain why they take SSRI's and many of them compare their treatment to the insulin required by diabetics. Because it all sounds scientific, it must be real and true, right?
But what now? How are we to understand the field now when so much of the research is tainted? And so many have a vested interest in the protocols which have emerged from it? Greed on the part of those who receive payments from drug companies for hawking certain drugs or for their research is one thing, but greed plays a deeper and more pernicious role in this enterprise as well.
Many therapists that I know would prefer to practice outside of the current third party payment system. They chafe at the paperwork, at the intrusion into the treatment, at the fact that they cannot set fees or frequency according to the needs of the patient but rather according to the insurance paying for the treatment. But they stay in the system because of greed, their own and their patients'. When patients must pay out of pocket for treatment, it is a lot harder to collect $100/hr or more for therapy. But when insurance picks up the tab for some or most of it, higher fees are possible. Patients are happy because they pay less per visit; therapists are happy because they receive more income. I am not saying that there is something evil or sleazy about this -- it is not in the same league as accepting hundreds of thousands of dollars for biased work -- but it is about greed.
In fact, the entire system is built on greed. Maximizing income while minimizing payment has been driving the system for around 20 years at least. Insurance companies want to pay out the least amount possible that they might be profitable and please their shareholders. Pharmaceutical companies want their drugs prescribed as frequently as possible in order to maximize profit and please their shareholders. Psychiatrists want to earn at the levels many of their physician colleagues in other specialities earn so they do what yields the most income and they withdraw from providing psychotherapy and turn increasingly to medication practices. Psychologists and social workers want to earn more so they accept the intrusions of insurance companies in order to charge higher fees. Patients want to pay as little as they can so they choose therapists who will accept their insurance which will pay for the sessions even if treatment gets interrupted before it is completed.
At the level of the practitioner and patient, greed is almost certainly not a conscious motive but it is a driving factor nonetheless. That hardly anyone is trained in any method other than CBT these days is not because it is the most effective approach -- we have research emerging pretty regularly now that other approaches work as well or better. It is because it is most easily regulated and controlled by the insurance companies who pay the bills that allow the therapists to earn a healthy income and patients to pay out very little. Greed.