Slate Star Codex

The first thing you notice at the American Psychiatric Association meeting is its size. By conservative estimates, a quarter of the psychiatrists in the United States are packed into a single giant San Francisco convention center, more than 15,000 people.

Being in a crowd of 15,000 psychiatrists is a weird experience. You realize that all psychiatrists look alike in an indefinable way. The men all look balding, yet dignified. The women all look maternal, yet stylish. Sometimes you will see a knot of foreign-looking people huddled together, their nametags announcing them as the delegation from the Nigerian Psychiatric Association or the Nepalese Psychiatric Association or somewhere else very far away. But however exotic, something about them remains ineffably psychiatrist.

The second thing you notice at the American Psychiatric Association meeting is that the staircase is shaming you for not knowing enough about Vraylar®.

Seems kind of weird. Maybe I’ll just take the escalator…

…no, the escalator is advertising Latuda®, the “number one branded atypical antipsychotic”. Aaaaaah! Maybe I should just sit down for a second and figure out what to do next…

AAAAH, CAN’T SIT DOWN, VRAYLAR® HAS GOTTEN TO THE BENCHES TOO! Surely there’s a non-Vraylar bench somewhere in this 15,000 person convention center!

…whatever, close enough.

You know how drug companies pay six or seven figures for thirty-second television ads just on the off chance that someone with the relevant condition might be watching? You know how they employ drug reps to flatter, cajole, and even seduce doctors who might prescribe their drug? Well, it turns out that having 15,000 psychiatrists in one building sparks a drug company feeding frenzy that makes piranhas look sedate by comparison. Every flat surface is covered in drug advertisements. And after the flat surfaces are gone, the curved sufaces, and after the curved surfaces, giant rings hanging from the ceiling.

The ads overflow from the convention itself to the city outside. For about two blocks in any direction, normal ads and billboards have been replaced with psychiatry-themed ones, until they finally peter off and segue into the usual startup advertisements around Market Street.

There’s a popular narrative that drug companies have stolen the soul of psychiatry. That they’ve reduced everything to chemical imbalances. The people who talk about this usually go on to argue that the true causes of mental illness are capitalism and racism. Have doctors forgotten that the real solution isn’t a pill, but structural change that challenges the systems of exploitation and domination that create suffering in the first place?

No. Nobody has forgotten that. Because the third thing you notice at the American Psychiatric Association meeting is that everyone is very, very woke.

Here are some of the most relevant presentations listed in my Guidebook:

…you get the idea, please don’t make me keep writing these.

Were there really more than twice as many sessions on global warming as on obsessive compulsive disorder? Three times as many on immigration as on ADHD? As best I can count, yes. I don’t want to exaggerate this. There was still a lot of really meaty scientific discussion if you sought it out. But overall the balance was pretty striking.

I’m reminded of the idea of woke capital, the weird alliance between very rich businesses and progressive signaling. If you want to model the APA, you could do worse than a giant firehose that takes in pharmaceutical company money at one end, and shoots lectures about social justice out the other.

The fourth thing you notice at the American Psychiatric Association meeting is the Scientologists protesting outside.

They don’t tell you they’re Scientologists. But their truck has a link to CCHR.org on it, and Wikipedia confirms them as a Scientology front group. Scientology has a long-standing feud with psychiatry, with the psychiatrists alleging that Scientology is a malicious cult, and the Scientologists alleging that psychiatry is an evil pseudoscience that denies the truth of dianetics. And that psychiatrists helped inspire Hitler. And that the 9/11 was masterminded by Osama bin Laden’s psychiatrist. And that psychiatrists are plotting to institute a one-world government. And that psychiatrists are malevolent aliens from a planet called Farsec. Really they have a lot of allegations.

This particular truck is especially sad, because they’re reinforcing the myths about electroconvulsive therapy. ECT is a very effective treatment for depression. It is essentially always consensual – although most other psychiatric treatments can be administered involuntarily if someone is judged too out-of-touch with reality to make decisions, ECT has a special status as a treatment which can only be given with patient permission. It’s always performed under anaesthesia and muscle relaxants, so patients are not conscious during the procedure and not spasming. And it can be a life-changing option for treatment-resistant depression. See this Scientific American article for more.

The fifth thing you notice at the American Psychiatric Association meeting is that the CIA has set up a booth.

I was pretty curious about what the CIA wanted from psychiatrists (did they lose the original MKULTRA data? do they need to gather more?), but I was too shy to ask their representative directly. I did take one of their flyers, but it turned out to just be about how woke they were:

The sixth thing you notice at the American Psychiatric Association meeting is that Vraylar® has built an entire miniature city. The buildings are plastered with pamphlets on Vraylar®. Billboards advertising Vraylar® hang over the streets and bridges. Giant Vraylar balloons hover serenly over everything, looking down with contempt and sorrow upon the non-Vraylar®-prescribing world below.

Occupying pride of place in city center, some sort of Important Vraylar Scientist is constructing the Transamerica Pyramid out of playing cards.

I dunno, if I were working in an area where the research supporting a treatment has a tendency to collapse suddenly and spectacularly, I might want to avoid building an association in people’s minds between my medication and a house of cards. But the ways of Vraylar® are inscrutable to mortal men.

The seventh thing you notice at the American Psychiatric Association meeting is that many of the new drugs are ridiculous.

It’s hard to blame pharmaceutical companies for this. The return on investment for pharma R&D is rapidly shrinking – drug discovery is too expensive to consistently make money anymore.

Rather than give up and die, pharma is going all in on newer, me-too-er me-too drugs. The current business plan looks kind of like this:

1. Take an popular older drug

2. Re-invent it, either with a minor change to the delivery mechanism, or by finding a similar molecule that works the same way

3. Call this a new drug, advertise the hell out of it, and sell it for 10x – 100x the price of the older drug

4. Profit!

Consider Lucemyra®:

It’s an alpha-2a receptor agonist used to treat acute opiate withdrawal. Alpha-2a receptor agonists are a fine choice for acute opiate withdrawal, but we already have one that works great: clonidine. Clonidine costs $4.84 per month. Lucemyra® costs $1,974.78. Is there any difference at all between the two medications? Some studies suggest maybe lofexedine can cause less hypotension, but realistically we throw random doses of clonidine at ADHD kids all the time, so it’s not like clonidine-induced hypotension is some kind of giant menace which will destroy us all.

I asked the Lucemyra® representative why I might prescribe Lucemyra® instead of clonidine for opiate withdrawal. She said it was because Lucemyra® is FDA-approved for this indication, and clonidine isn’t. This is the same old story as Rozerem® vs. melatonin, Lovaza® vs. fish oil, and Spravato® vs. ketamine. As long as doctors continue to outsource their thinking to the FDA approval process, in a way even the FDA itself doesn’t endorse, pharma companies will be able to inflate the prices of basic medications by a thousand times just by playing games with the bureaucracy.

But also:

Jornay® is a new form of methylphenidate, ie Ritalin. The usual comparison: a month of Ritalin costs $25.19, a month of Jornay® costs $387.48. What’s the difference? You can take Jornay® at night. Why is this interesting? The Jornay® representatives say that maybe people want to have Ritalin in their system as soon as they wake up, rather than having to wait the half-hour or so it usually takes for it to start having an effect. I have to admit, from a scientific perspective Jornay® is kind of cool; I expect the pharmacologists who designed it had a lot of fun. But the oppressed people of the world haven’t exactly been crying out for Dark Ritalin. Nobody has been saying “Help us, pharmaceutical industry, merely having Ritalin®, Concerta®, Metadate®, Focalin®, Daytrana®, Quillivant®, Quillichew®, Aptensio®, Biphentin®, Equasym®, Medikinet®, and Rubifen® just isn’t enough for us! We need more forms of Ritalin, stat!”

My favorite was Subvenite®, which is just lamotrigine in a conveniently-packaged box that tells you how much to take each day. The same amount of normal lamotrigine would cost about $12; it’s hard for me to figure out exactly how much Subvenite® costs, but this site suggests $540. To be fair, lamotrigine is a really inconvenient drug whose dosing schedule often leaves patients confused. To be less fair, seriously, $540 for some better instructions? Get a life.

How do all these people keep doing it? What’s their business plan? Here’s a hint:

This is the brochure for Lucemyra®, the opiate withdrawal medication that costs $1,974.78. No patient is paying $1,974.78 for it. Patients are paying $25. And doctors sure aren’t paying $1,974.78. The way all these companies are getting away with it is because in Healthcaristan SSR, nobody ever pays for their own medication.

To a first approximation, doctors make purchasing decisions, but insurances cough up the money. Insurances have a few weapons to prevent doctors from buying arbitrarily expensive drugs, but they tend to back off in the face of magic words like “I believe this is medically necessary” or “This is the one the FDA approved”. So to fill in the missing pieces of the pharma strategy mentioned above:

1. Take an popular older drug

2. Re-invent it, either with a minor change to the delivery mechanism, or by finding a similar molecule that works the same way

3. Call this a new drug, advertise the hell out of it, and sell it for 10x – 100x the price of the older drug

4. Advertise it to patients (who don’t have to pay for it) and doctors (who definitely don’t have to pay for it), neither of whom care at all what price you’re setting.

5. Make sure doctors know the magic words they need to use to force insurance companies to pay for it.

6. Profit!

This has become so lucrative that pharma companies barely have to do any real research and development at all these days. The only genuinely exciting new drugs at the conference were Ingrezza® and Austedo®, both of which treat tardive dyskinesia – a side effect you get from having been on too many other psychiatric drugs. This is probably a metaphor for something.

The eighth thing you notice at the American Psychiatric Association meeting is that there’s a presentation called “Yer A Psychiatrist, Harry!”: Learning Psychiatric Concepts Through The Fictional Worlds Of Game Of Thrones And Harry Potter. I didn’t go. I realize I have failed you, my readers, but if I had to listen to ninety minutes of that, all the Vraylar® in the world would not be enough to maintain my sanity.

The ninth thing you notice at the American Psychiatric Association meeting is that, after winning last place in a head-to-head comparison of various antipsychotics, doing worse than drugs that cost less than 1% as much…

…Fanapt® (iloperidone) has pivoted to a marketing strategy of bribing doctors with free ice cream:

The tenth thing you notice at the American Psychiatric Association meeting is that all of this has happened before.

This is the 175th anniversary of the APA. It’s been a pretty crazy century-and-three-quarters, no pun intended. Like, seriously, take a look at this guy:

Back when you could still lose your medical license for being gay, he went to the APA meeting in a mask and gave a presentation arguing for gay rights, and the APA de-listed homosexuality as a psychiatric disorder the following year. How amazing is that?

The APA highlighted a bunch of people like this, heroes and trailblazers all. But for every great hero celebrated on posters, there is an embarrassment buried somewhere deep in an archive. My favorite of these is the APA Presidential Address from 1918, the very tail end of WWI. The head of the Association, a very distinguished psychiatrist named Dr. Anglin, gets up in front of the very same conference I attended this week (the 1918 version was held in Chicago) and declared that the greatest problem facing psychiatry was…the dastardly Hun:

The maxim that medical science knows no national boundaries has been rudely shaken by the war. The Fatherland has been preparing for isolation from the medical world without its confines. Just as, years ago, the Kaiser laid his ban on French words in table menus, so, as early as 19 14, German scientists embarked on a campaign against all words which had been borrowed from an enemy country. A purely German medical nomenclature was the end in view. The rest of the world need not grieve much if they show their puerile hate in this way. It will only help to stop the tendency to Pan-Germanism in medicine which has for some years past been gaining headway. ‘

The Germans excel all other nations in their genius for advertising themselves. They have proved true the French proverb that one is given the standing he claims. On a slender basis of achievement they have contrived to impress themselves as the most scientific nation. Never was there greater imposture. They display the same cleverness in foisting on a gullible world their scientific achievements as their shoddy commercial wares. The two are of much the same value, made for show rather than endurance — in short, made in Germany […]

In the earliest months of the war it was pointed out that there are tendencies in the evolution of medicine as a pure science as it is developed in Germany which are contributing to the increase of charlatanism of which we should be warned. A medical school has two duties — one to medical science, the other to the public. The latter function is the greater, for out of every graduating class 90 per cent. are practitioners and less than 10 per cent, are scientists. The conditions in Germany are reversed. There, there were ninety physicians dawdling with science to every ten in practice. Of these 90, fully 75 per cent were wasting their time. In Germany the scientific side is over-done, and they have little to show for it all, while the human side is neglected. Even in their new institutions, splendid as they are in a material sense, it is easily seen that the improved conditions are not for the comfort of the patients.

Out of this war some modicum of good may come if it leads to a revision of the exaggerated estimate that has prevailed in English-speaking countries of the achievements of the Germans in science. We had apparently forgotten the race that had given the world Newton, Faraday, Stephenson, Lister, Hunter, Jenner, Fulton, Morse, Bell, Edison, and others of equal worth. German scientists wait till a Pasteur has made the great discovery, on which it is easy for her trained men to work. She shirks getting for herself a child through the gates of sacrifice and pain ; but steals a babe, and as it grows bigger under her care, boasts herself as more than equal to the mother who bore it. Realising her mental sterility, drunk with self-adoration, she makes insane war on the nations who still have the power of creative thought.

But it is especially in the realm of mental science that the reputation of the Germans is most exalted and is least deserved. For every philosopher of the first rank that Germany has produced, the English can show at least three. And in psychiatry, while we have classical writings in the English tongue, and men of our own gifted with clinical insight, we need seek no foreign guides, and can afford to let the abounding nonsense of Teutonic origin perish from neglect of cultivation.

The Germans are shelling Paris from their Gothas and their new gun. Murdering innocents, to create a panic in the heart of France! With what effect ? The French army cries the louder, “They shall not pass ” ; Paris glows with pride to be sharing the soldiers’ dangers, and increases its output of war material; and the American army sees why it is in France, and is filled with righteous hatred. Panic nowhere. Vengeance everywhere. What does the Hun know of psychology? His most stupid, thick-witted performance was his brutal defiance of the United States with its wealth, resources, and energy. That revealed a mental condition both grotesque and pitiable.

After the war a centre of medical activity will be found on this side the Atlantic, and those who have watched the progress medical science has made in the United States will have no misgivings as to your qualifications for leadership. If we learn to know ourselves, great good will come out of this war.

Anglin does not deny that some may find it inappropriate to discuss politics at a psychiatry conference, but notes that:

If in these introductory remarks I have not been able to detach myself from the world’s most serious business at the present time, perhaps on reflection they may not have gone very far afield from the subject which binds us together in an association. If there is to be a change in the conditions under which we live this must have its effect on the minds of men ; whether for good or ill, I will not stop to speculate. We are intensely concerned with environment. This war itself is entangled with it,

England’s greatness, her devotion to honour, truth, and fidelity, is due to the environment in which her children are trained and grow to manhood. The ivy-grown wall, the vine-clad hills and the rose-covered bowers constitute the birth-place of English character.

Gerard tells us the cause of the war is the uncongenial environment in which the German youth is cradled and reared. The leaden skies for which Prussia is noted, its bleak Baltic winds, the continuous cold, dreary rains, the low-lying land, and the absence of flowers have tended to harden the spirit and rob it of its virtue, produce a sullen and morose character, curdling the milk of human kindness.

He does raise one warning, one problem that risks sabotaging even countries as congenial-climate-having as ourselves and our allies:

The quack medicine vendor is busier than ever. Money is plenty and he wants some of it. He uses mental suggestion and interests us. He is a specialist in distortion who probes into the ordinary sensations of
healthy people and perverts them into symptoms. Every billboard, newspaper, fence-rail, barn and rock thrusts out a suggestion of sickness as never before. The only vulnerable point to attack the vicious traffic is the advertising. If governments forbid that as they should, the next generation will be healthier and richer.

From Dr. Anglin’s address, I gather three things.

First, the billboards we shall always have with us. It’s easy to imagine this a modern problem, but apparently the generation that confronted the Kaiser was confronting annoying psychiatric advertising too. The Kaiser is gone; the annoying psychiatric advertising has proven a tougher foe.

Second, psychiatry has always been the slave of the latest political fad. It is just scientific enough to be worth capturing, but not scientific enough to resist capture. The menace du jour will always be a threat to our mental health; the salient alternative to “just forcing pills down people’s throat” will always be pursuing the social agenda of whoever is in power; you will always be able to find psychiatrists to back you up on this.

But third, science advances anyway. Psychiatry is light-years ahead of where it was a hundred years ago. Since Dr. Anglin’s 1918 address, we’ve discovered psychotherapy and psychopharmacology; come up with deinstitutionalization and destigmatization; and put rights in place to protect psychiatric patients and to protect the general public from being unnecessarily psychiatrized. We’ve even invented Vraylar®.

On my way out of the conference, I encountered this ad:

I don’t think it was even related to the psychiatry conference. I think it was for a nearby art museum. But it struck me. It struck me because it’s the sort of picture psychiatry wants to have of itself, a combination of hard neuroscience and basic human goodness. It struck me because as written, it’s obviously bogus (which Brodmann area is responsible for empathy again? How bright does it have to light up before you start feeling empathic?) in much the same way psychiatry can be obviously bogus (how much Vraylar® does it take before you can “take back control of your life” or “feel better than well”?), but is sort of an exaggerated and slightly-too-literal version of something that could potentially not be bogus. It struck me because, after making fun of it, I had to admit to myself that the thing it was pointing at was good and important and probably exactly what an art museum should be trying to do. And a psychiatrist, for that matter.