June 14, 2008

Say It Ain't So Joe

On Psychology Today's blog. June 14, 2008

Most parents have never heard of him but Joseph Biederman, head of Harvard's Massachusetts General Child Psychopharmacology Clinic, may be the most influential doctor when it comes to determining whether or not children are normal or mentally ill in America.

That’s why the New York Times report last Sunday on Senator Charles Grassley’s revelation that Biederman did not declare over $1.5 million in drug company consulting fees is so important, scary and tragic. If true, this scandal is yet one more stake in the heart of American academic medicine’s credibility with front-line doctors like myself and more importantly with the parents of the patients I deal with everyday.

The state of the science of children’s psychiatric medications is so primitive and Dr. Biederman’s influence so great that he may merely mention the name of a drug in passing during a presentation and within a year or two, tens of thousands of children will be taking that drug or combination of drugs – based upon word of mouth between the seven thousand child psychiatrists in America – and even in the absence of a drug trial of any kind.

In 1996 Biederman suggested that drugs like Ritalin might serve ten per cent of American kids for ADHD. By 2004, one in nine eleven year old boys was taking the drug. Also in 1996 Biederman “shocked” the established child psychiatric community by announcing pediatric bipolar disorder criteria that were so broad as to include nearly one quarter of all his ADHD clinic patients. Indeed, by 2008 Biederman and his team at Harvard are more responsible than anyone else for the child bipolar epidemic sweeping America (and no other country) that has two year olds on three or four psychiatric drugs and now, one famous (or infamous) ten year old Newsweek cover boy named Max, who has taken 38 different psychiatric medications in his short unhappy life.

I remember about six years ago my dismay when on the same day I read in the main professional journal of child psychiatry a major article by the Biederman team on the advantages of a non-Ritalin drug pathway for ADHD, I also heard him giving a speech for a Wall Street audience in New York promoting a new drug by Eli Lilly called Strattera. Strattera turned out to be rather a bust both clinically and commercially for ADHD but still I was shaken that so prominent a researcher could be so brazen with his potential conflict of interest appearance.

So what does it mean that Biederman didn’t declare the money? The $1.5 million is only a small fraction of the full amount of research funding Biederman’s clinic receives from at least a half-dozen companies that pay for both the cost of running studies but also the salaries of the doctors involved. Virtually every doctor who receives drug company money says they are not influenced, but nearly every independent study examining the effects of such money says they are. At least Biederman can claim no one company has his ear solely.

The leadership of Harvard’s psychiatry department is strangely silent or even defends Dr. Biederman. These are good men with solid reputations both in drug and non-drug aspects of treatment. Yet they know that their psychiatry department would not exist were it not for drug company money -- what with the withdrawal of federal research dollars over the past twenty five years and the meager reimbursements psychiatrists receive for their services from insurance companies and Medical.

American medicine, with psychiatry the most culpable, has fallen back to a time more than a hundred years ago when doctor credibility was tantamount to the promotion of patent medicine. The Welch and Flexner reforms completely severed ties between medical school doctors and the drug industry – and for decades subsequently there existed a much more ethical balance between the industry and physicians.

This time, I thought reform would only come from outside the medicine – from trial lawyers, government and ultimately big business whose health insurance costs must pay for all of those very expensive me-too trade drugs. However, some small signs within the profession encourage me -- like the growth in the interest for the Carlat Psychiatry Report published by a courageous independent front-line psychiatrist who scrupulously examines paid psychiatric research and refuses all advertisements for his newsletter. More recently, I’m proud of the American Medical Students Association which has put pressure on medical faculty by publicly grading from A to F medical schools throughout the country for their conflict of interest policies.

Now I wait for Dr. Biederman’s explanation and the usual suspects rushing to his defense. But ninety years ago painful news about another “Joe” (Joe Jackson of the 1919 Chicago Black Sox) had the country wishing “Say it ain’t so.” It is with great sadness, I wonder, whether it is not now Dr. Biederman’s turn.


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