ACADEMY FORUM - The American Academy of Psychoanalysis and Dynamic ...

is doing a phenomenal job putting together a stellar program
committee. I encourage all AAPDP members to contact me if interested
in attending or presenting in WPA meetings worldwide.
Although I am a relatively newcomer to the WPA community,
we can bond in exploration of rich academic exchanges.
I am honored that Richard Friedman asked me to step up
and join Jennifer Downey as Deputy Editor of Psychodynamic
Psychiatry. Part of my mandate and Rick’s vision of the journal
is to increase international exposure and participation. I look
forward to this challenge with humility and great enthusiasm.
AAPDP President Michael Blumenfield has made it clear that
international exposure and development is an important part of
his platform. I will assist him with energy and scholarly effort.
The AAPDP will continue to be my academic home base. All
of my mentors are AAPDP members and I am committed to
preserve the Academy’s legacy through mentoring and scientific
pursuits.
My father got his M.D. in
1930; I got mine in 1958. Insulin
and penicillin came into
being during his early years of
practice. In my first years as a
psychiatrist, tranquilizers and antidepressants
changed the landscape
of mental health. As doctors, Dad
and I both welcomed Medicare in
1965; later on as patients we became
grateful beneficiaries.
I remember him explaining “ethical pharmaceuticals” - a term
that distinguished companies like Merck from hucksters of “patent
medicines.” The scandal at Merck about the arthritis drug Vioxx
came after his time - he would have been appalled.
Recently the line between ethical drug companies and hucksters
was blurred by GlaxoSmithKline, which paid a record fine for its
bad acts. Until this Glaxo case, drug firms took fines and some
bad publicity in stride as a cost of business; now the companies
and Wall Street are getting a new message.
Medicine is a profession - a calling, not a business. In Dad’s
lifetime it was unethical for doctors, hospitals and pharmaceutical
companies to advertise. Now it is legal, and presumably ethical,
to peddle prescription drugs to patients who get doctors to swing
at the advertiser’s pitch. Doctors earn much more for prescribing,
testing and treating than for explaining. Insurance pays for the
expensive drug. How many doctors will take the time to suggest
a cheaper generic drug with an excellent track record
Direct-to-consumer (DTC) advertising is legal in only two
countries, the U.S. and New Zealand. It’s a very profitable exercise
of free speech for commercial broadcasters that lease our
public airwaves.
Although most doctors oppose DTC advertising, medical associations
are no match for the combined force of Big Pharma and
the TV networks. Drug companies spend far more on marketing
than on research. Profits come mainly from new drugs under
patent, only some of which have been proved better than less
expensive, well-tested generic drugs.
The Food and Drug Administration has been a muffled watchdog,
where political pressure for new drugs could trump research.
Enormous quantities of psychiatric drugs - chiefly antidepressants
and antipsychotics - flow through the blood streams of Americans;
the residues are measurable in municipal effluent waterways. Psychiatrists
are only four percent of physicians, so most psychiatric
drugs are prescribed by nonspecialists. The “depression hurts” ads
that say “ask your doctor” do not mean your psychiatrist!
Medicare, a huge benefit to older Americans, has been effective
Drug Ads vs. Psychotherapy
by E. James Lieberman, M.D.
10
partly because of its nonprofit single-payer system. Unfortunately,
the program suffers from too little government regulation. Prescriptions
are paid for with little or no attention to comparative
efficacy, safety, and cost. Unlike the Veterans Administration,
Medicare cannot negotiate lower drug prices. Elderly patients are
routinely overmedicated, and too often hospitalized when home
care is preferable.
Private health insurance is stricter than Medicare in some
ways, but not with pharmaceuticals. Despite cautionary teaching
in medical schools, rampant overprescription of antibiotics has
created monsters - resistant bacteria that threaten us in everything
from hospitals to handshakes. With its airwaves full of prescription
drug ads, our government must protect citizens against halftruths
masquerading as health education.
The new ED, formerly “impotence,” was created by corporate
greed, not medical need. Most of the over 20 million men (according
to ads) who’ve asked their doctors about sexual insufficiency
have a psychological or relationship problem. The vast
majority of doctors prescribing ED drugs are neither psychiatrists
nor urologists: they have little time, interest - even training - for
a good sexual history. They should, but won’t, interview the
patient with his partner - a basic diagnostic step. For a few patients
with organic disease the drug is a worthwhile treatment;
for most it’s a permanent crutch, a costly and possibly unhealthy
drug dependence.
The American Psychiatric Association (APA) has done little to
help. Psychiatrists don’t want to criticize other physicians, and
the APA itself depends on drug ads for its periodicals. Clinical
psychologists and marital therapists who do not prescribe drugs
are better equipped for couples work than psychiatrists, who earn
much more for three medication sessions an hour than for one
session of talk therapy. Of course, there are no ads for psychotherapy
or marriage counseling.
Americans have a weakness for the pill, the quick fix. Patent
medicine makers are happy to habituate them. The obligatory
list of awful side effects seems to be no deterrent. ED is a special
case, at a time when Internet porn has become increasingly
obscene in order to produce the excitement that readers once got
from a D. H. Lawrence novel.
These days a curious child can only wonder about an erection
that lasts more than four hours, and concerned adolescents might
wonder about how long they have before ED sets in. Pharmaceutical
and network executives are parents and grandparents, too.
How would they answer these questions
E. James Lieberman, M.D., M.P.H. is a Clinical Professor of
Psychiatry, Emeritus, at the George Washington University School
of Medicine. His email address is ejl@gwu.edu