Psychiatry and the Pharmaceutical Companies

A patient of mine recently asked if all doctors are as gullible to the pharmaceutical companies’ marketing tricks as it appears. I was immediately transported to my days working in an academic hospital. At the time, the "drug reps," as they are called, used to have much more leeway to befriend and bribe exhausted and overstressed trainees eager for free food and a friendly smile. The companies knew better than we that our future prescribing practices were at stake. Falsely armed with  a lethal combination of arrogance and naïveté, we medical residents assumed that we could toe the line as excellent clinicians while exploiting big pharma largesse. Even our respected mentors encouraged us to at least listen to the pharmaceutical information--advertisements disguised as clinical trials--while eating our free lunch. According to the hospital's motto, we were the "Best of the West" and that meant being fully capable of prescribing all of the newest medications, even if the only supporting data were generated by the drug company itself.

In the ten years that have passed, I have worked primarily in private practice. One of my first decisions was to eliminate all pharmaceutical company influence. I rebuff phone calls from reps every week, occasionally escort the brazen marketer, who appears unsolicited in the waiting room, to the door and regularly ignore invitations to dinners at some of New York's posh restaurants. In the meanwhile, I have also disregarded the bulk of clinical trials studying the newest drugs, even in the prestigious journals, since most of the funding for this research continues to come from the pharmaceutical companies themselves.

During my training, I believed I was simply acting according to my beliefs. Unlike many of my colleagues, I never believed I was immune to these sophisticated marketing techniques, and I wanted to practice apart from from these influences. What has surprised me through this past decade is the transformation of my prescribing practices. First, I have raised my threshold as to whether or not to prescribe medication at all. In an age when medication is supposed to cure all our ills, the default decision of a psychiatrist is to medicate and always medicate. It is liberating to know that prescribing is a clinical decision, not an automatic action. I also take into account variables never mentioned by a pharmaceutical rep: long-term safety data, years of efficacy with substantial independent research, and, finally, price.
Accordingly, I face the challenges of practicing psychiatry in a very different way. I have gravitated to routinely using medications that came on the market over 20 years ago because the safety record is proven and therefore puts patients and me at ease. I avoid new medication combinations and instead choose older, more thoroughly studied options, such as thyroid medication for depression--a treatment which has safety and efficacy data starting from the 1950s. I also weigh price into the equation both for my patient's pocketbook and to measure my small footprint on the explosion of health care costs.

The uneasy marriage between academic medicine and big business has had significant costs to medicine as well as to society at large. Physicians, by nature, are not business people. In recent years, several highly-esteemed physicians have been caught lining their pockets with pharmaceutical payouts while using their reputations to successfully sway doctors' prescribing practices. Clearly, no one is immune to such cutthroat and well-practiced marketing schemes. Left to their own devices, insulated from sales pitches cynically disguised as education, doctors might find alternate ways to differentiate between the true goals of a healing profession and the hidden influences of the marketplace. Protecting young doctors from powerful marketing influences early in their careers could have long-term safety benefits and help rescue the medical profession from the aura of skepticism and distrust that has come to surround it.


The Recovered Treating the Ill: Why so many Clinicians had Eating Disorders Themselves

The clinicians who treat people with eating disorders have often themselves suffered from anorexia or bulimia. Little has been written about having the recovered treat the ill, but informal conversations quickly reveal strong reactions from patients and clinicians alike. In fact, many programs and individuals fall in one of two camps: those who think only someone who had an eating disorder can be an effective therapist and those who think that this creates a community of people who never get well.

Although everyone's goal is successful treatment, there is something about eating disorders that generates emotional and even political factions. The confusion only grows deeper as these illnesses burrow further into the modern ethos. The multiple possible causes, limited therapeutic options and endless debate of disease vs. lifestyle choice opens the door for multiple, unsubstantiated and fractious theories.
The movement for the recovered to treat the ill has a clear precedent. Addiction treatment has been notoriously challenging and largely unsuccessful. Alcoholics Anonymous, a peer sponsored, ongoing support network with a clear program and 24 hour system provides what no treatment option can. The components include a group of people like-minded in the desire for recovery with similar experiences and a formula for success. Most important, when an addict feels the craving, there are many people only a phone call away.
Similar to addiction, it remains very difficult for people without eating disorders to understand and have compassion for the incessant mental torture of these diseases. Trying to live in the world while struggling to eat at every meal creates a very isolating existence. The deep sense of loneliness and separateness of the recovery process experience remains a barrier to getting well. The psychological and emotional pain often makes the potential relief of the eating disorder symptoms irresistible.
Understanding why eating disorder recovery is such a lonely experience is very hard. However, everyone can identify with the actual feeling of being alone. One irony of the human condition is that the feeling of being alone in the world is universal. How can we all share together the reality of being so alone? Although feeling part of a group always alleviates this ill, the relief is always fleeting.
In the eating disorder community, the banding together of the recovered and the ill creates just such solidarity. A group of people whose experience runs the gamut from very sick to fully healed can embody the entire scope of the process in one room and generate hope in a way that is at the core of any successful treatment. Seeing a therapist who communicates hope just by being there and saying "I am well" can change the tenor of recovery. In the throes of the daily struggle to eat and get well, a daily reminder of hope is invaluable.
There is one critical, potential pitfall. In any group with people still quite sick with an eating disorder, the internal drive back to starving or binging remains strong. In the face of powerful forces that everyone in this group has experienced, there has to be a constant, overt undercurrent that recovery is the goal. This may seem obvious but many well-intentioned groups have succumbed to the power of relapse. The fundamental notion, borne out of AA, is to respect the disease. As long as even the members with the longest recovery acknowledge the risk of relapse, the group as a whole will remain on track.
What clinicians without an eating disorder provide is perspective. Treatment acts as a bridge from sick to well and from isolation to connectivity. To exist in a therapeutic environment simultaneously without judgment and with the luxury to be fully honest liberates a patient from the prison of an eating disorder. Nestled solely in the arms of the recovered, a patient will remain scared to be in the world. A clinician from the outside can help that person learn how, even with the history of an eating disorder, to be in the wider world.
The community of practitioners--the recovered and the outsiders--need to stay together. The treatment of eating disorders need not be a political battleground between the afflicted and the perpetrators. It need not foster the endless debates of illness or imposed prison. Yes, the social forces behind the steep rise in eating disorders in recent decades are polarizing, but it is the clinician's job to heal. Let's put aside the disparate motives and agree that there are many, many sick people in need of help to get well.


Talking Fat and Thin with your Kids, Part II

It's a parent's job to translate a child's words and behaviors and then figure out how best to respond. Without the benefit of clear language and emotional regulation, children make basic comprehension of their actions difficult. In this day and age, a child's statement of "I feel fat" is just such a challenge.

Parents tend to interpret children largely based on the prevailing life philosophy. Following the most popular parenting books through successive generations is a great way to learn about the evolution of kids' expected roles in society. Parents, more often than not, will gladly accept any advice offered, so parenting guide books tend to be popular. Raising children is too daunting a task to leave parents with much energy to argue with the supposed experts. As the philosophy seeps into a generation, kids are gradually assimilated into their culture.
The current mode of healing in any day and age strongly influences the approach parents use to comprehend a child's baffling reactions to daily life. Often the most trusted member of the community is the designated healer. 
The concept of therapist as healer--an ignominious status passed down from shaman to minister to psychoanalyst and now to therapist--has had a profound effect on how we live our lives today and, in communities focused on youth, how parents treat children.
Therapy, taken as a whole, presents many theories that can be used to understand children. There is a vast therapy literature that explores a child's use of play and transitional objects and another that focuses on the conflicts that arise in each stage of maturation, but the lay person's current takeaway message from a world of therapy is very different.
The current parenting book is now an adult-centered self-help paperback. A quick and easy read with a few throwaway lines you forget within an hour or two. Rather than interpreting a child's behavior as a clue to their current needs, the premise of these books is to wonder what might be going on in their little minds, as if they are just small adults.
Children no longer have the free pass of just being kids. The endless stream of self-help mantras and boiled-down therapy nuggets has led parents to apply adult advice to a growing child. Kids are now mistakenly seen as little grown-ups with mature motivations and emotions and are regularly misunderstood.
The over-analyzing and rationalizing of a child's behavior leads parents to ascribe sophisticated motives to the haphazard flailing of an animal that is all id. The bygone world less preoccupied with a child's inner workings left kids to their own devices to sort through personal development and hoped for the best. Now, watched at every turn, kids have each moment scripted practically from birth.
The end result is little freedom to engage in play and experiential learning and little time for a key part of childhood, self-exploration. At activity after activity, kids perform a task and search an adult's knowing gaze for approval. Kids don't flounder in the feeling of insecurity and confusion; there is no time or reason for that. They have been trained to look to the adults in their lives for signs not only of how they're doing, but of who they ought to be.
Treated as mini-adults and left little space for development of an identity, kids have resorted to adult language--such as "I feel fat"-- to try to express any sense of unhappiness. Because kids are seen as little people, parents and clinicians alike are apt to treat a child's comment about feeling fat at face value. The two possible interpretations undoubtedly magnify and sometimes even create a problem that was never there.
One option is to actually believe the child and put her on a diet. This step, meant, in therapist lingo, to validate the child's worry, only confirms that she is fat and encourages the descent into an eating disorder.
The second is to be the proactive parent and treat this comment as if the child already has an eating disorder. Unbeknownst to the worried adult, children have little ability to distinguish between looking for a problem and having one. Thus, the child will now believe that, magically, one statement itself is enough to constitute an eating disorder.
Just as the eating disorder treatment adage "It's not about the food" explains, this isolated comment is not about feeling fat. One of the biggest challenges with children is that they don't have the ability to express what's going on inside them. It is the privilege of adolescence and young adulthood to learn how to meld our emotional and rational worlds. And the truth is that doing it well is a life's work.
Often, in children, emotions come out in physical ways, like a headache or stomach ache, tantrums or, as in this case, copying the expressions of adults around them. So a parent, spooked by this comment, has to table the initial fear. Any emotional reaction by an adult will spark the child's interest, the opposite of the desired response. Just asking the child what's wrong will get you nowhere. Saying "I feel fat" was all the child knew how to say. This is a situation for the parent to do a bit of sleuthing to understand what's going on.
The first thing to look at is the child's behavior. Kids really at risk will be restricting food, secretly binging or obsessively checking their bodies, even as young as age five or six. If the only red flag is "I feel fat," without any eating disorder behaviors, then this comment is very unlikely to represent the start of an illness.
After dismissing the worst case scenario, however, this isn't the moment to ignore the comment. Any child aware of the adults and media around them knows that feeling fat is a way to express that something is wrong. Without another way to say it, this child is using sophisticated adult shorthand to get someone to understand. This is an opportunity to poke around at school about academics or friendships, to talk to teachers or other parents and suss out what might be going on. That way, the child will see that you know there is a problem, even if feeling fat has nothing to do with it.