Yet Another Pharma Company Pays Huge Fine for Misleading Marketing

On my post of May 8, 2012, I reported that, after a rash of huge United States Justice Department fines against various large drug companies for deceptive marketing of drugs used in bipolar disorder and other psychiatric conditions, two states picked up the gauntlet. The states of South Carolina and Arkansas fined Ortho-McNeil-Janssen Pharmaceuticals, a subsidiary of Johnson and Johnson, for overstating the effectiveness and minimizing the risks of their antipsychotic medication Risperdal.

The company responsible for this deceptive advertising was one that had somehow escaped the scrutiny of the federal government.

Until now.

There is this from the US Department of Justice. This same company was fined 2.2 billion dollars for misleading and deceptive advertising for this medication. (My posts about this sort of thing are getting just plain routine, and a bit tiresome):

 "WASHINGTON - Global health care giant Johnson & Johnson (J&J) and its subsidiaries will pay more than $2.2 billion to resolve criminal and civil liability arising from allegations relating to the prescription drugs Risperdal, Invega and Natrecor, including promotion for uses not approved as safe and effective by the Food and Drug Administration (FDA) and payment of kickbacks to physicians and to the nation’s largest long-term care pharmacy provider.  The global resolution is one of the largest health care fraud settlements in U.S. history, including criminal fines and forfeiture totaling $485 million and civil settlements with the federal government and states totaling $1.72 billion....

In a criminal information filed today in the Eastern District of Pennsylvania, the government charged that, from March 3, 2002, through Dec. 31, 2003, Janssen Pharmaceuticals Inc., a J&J subsidiary, introduced the antipsychotic drug Risperdal into interstate commerce for an unapproved use, rendering the product misbranded.  For most of this time period, Risperdal was approved only to treat schizophrenia.  The information alleges that Janssen’s sales representatives promoted Risperdal to physicians and other prescribers who treated elderly dementia patients by urging the prescribers to use Risperdal to treat symptoms such as anxiety, agitation, depression, hostility and confusion.  The information alleges that the company created written sales aids for use by Janssen’s ElderCare sales force that emphasized symptoms and minimized any mention of the FDA-approved use, treatment of schizophrenia.  The company also provided incentives for off-label promotion and intended use by basing sales representatives’ bonuses on total sales of Risperdal in their sales areas, not just sales for FDA-approved uses.  

In a plea agreement resolving these charges, Janssen admitted that it promoted Risperdal to health care providers for treatment of psychotic symptoms and associated behavioral disturbances exhibited by elderly, non-schizophrenic dementia patients.  Under the terms of the plea agreement, Janssen will pay a total of $400 million, including a criminal fine of $334 million and forfeiture of $66 million.  Janssen’s guilty plea will not be final until accepted by the U.S. District Court...

In a related civil complaint filed today in the Eastern District of Pennsylvania, the United States alleges that Janssen marketed Risperdal to control the behaviors and conduct of the nation’s most vulnerable patients: elderly nursing home residents, children and individuals with mental disabilities.  The government alleges that J&J and Janssen caused false claims to be submitted to federal health care programs by promoting Risperdal for off-label uses that federal health care programs did not cover, making false and misleading statements about the safety and efficacy of Risperdal and paying kickbacks to physicians to prescribe Risperdal...

The complaint also alleges that Janssen knew that patients taking Risperdal had an increased risk of developing diabetes, but nonetheless promoted Risperdal as “uncompromised by safety concerns (does not cause diabetes).”  When Janssen received the initial results of studies indicating that Risperdal posed the same diabetes risk as other antipsychotics, the complaint alleges that the company retained outside consultants to re-analyze the study results and ultimately published articles stating that Risperdal was actually associated with a lower risk of developing diabetes."

So far, these huge fines have not seemed to have done a whole lot in discouraging this practice. The companies more than recoup the costs.

Pharma Still Up to its Old Tricks

It looks as though big Pharma is still up to one of its most disturbing practices: not publishing or making public studies that show that its products might be ineffective. As described by my colleague Peter Parry later in this post, we had thought this problem was successfully addressed back in 2010.  

Apparently not.

And do not think this problem is unique to psychiatric medications. 

Of course, as I have pointed out several times in this blog, recruitment and assessment of subjects for many research studies these days has become so warped by financial incentives that many of the studies, published or not, are not worth the paper they are printed on to begin with. 

And some studies are purposely designed to mislead readers into believing that certain generic drugs, particularly antidepressants, are not effective when in fact, when used properly for the right patients, they are among the most effective drugs in all of medicine. But that's a 'hole 'nuther issue.

To get back to the issue at hand:

From Medscape, 10/29/13: 

An analysis of nearly 600 registered clinical trials published online October 29 in BMJ has shown that 29% remained unpublished 5 years after completion, that no results were available in ClinicalTrials.gov for three fourths of those unpublished trials, and that industry-funded trials were nearly twice as likely to go unreported as studies that had not received industry funding.

Previous studies have shown that published trials contain less than half of the patient-outcomes data contained in company-controlled documents.

Dr. Jones and colleagues from the University of North Carolina, Chapel Hill, conducted a cross-sectional analysis of trials that had at least 500 participants and had been prospectively registered with Clinical Trials.gov and completed before January 2009. 

Their analysis included 585 registered trials, 171 of which (29%) remained unpublished. These unpublished studies included nearly 300,000 participants.

"By focusing our investigation on studies with at least 500 participants, we greatly limited the possibility that non-publication of trials in this cohort was due to rejection of manuscripts by journals or a lack of time or interest on the part of investigators or sponsors," the authors write.

The non-publication rate was 32% for industry-funded trials and 18% for those without industry funding (P = .003), and 78% of the unpublished trials also had no reported data in ClinicalTrials.gov.

From Peter Parry (on the webpage TheConversation.Edu.Au):

Dr. Peter Parry

A large proportion of drug trials, particularly those sponsored by pharmaceutical companies, never get published, skewing our picture of drugs' effectiveness and safety.

Research published in 2010 showed results unfavorable to sponsored drugs are less likely to be published, or selectively published to put a favorable spin on poor results.  And internal pharmaceutical industry documents released from court cases show concealment of data is a widespread practice.

A colleague and I assessed such documents about psychiatric medications from five pharmaceutical companies. The papers suggested widespread overstatement of benefits and understatement of adverse effects. Other researchers have found similar problems with different drugs.

In response, some medical journals voluntarily agreed to publish only studies registered on a website of the US National Institutes of Health, ClinicalTrials.gov. At least studies with unfavorable results would not be buried by drug companies. But the BMJ article confirms that many registered studies still don’t get published.

The AllTrials initiative aims to make the (de-identified) results and methodology of drug trials available to independent researchers so journals can publish in-depth articles based on all of the full data.

In 11 months, the campaign’s petition has gathered over 59,000 individual signatories and over 400 medical and health-care organizations. These include many British medical colleges and learned academic medical science institutions, such as the Cochrane Collaboration and the British National Institute for Health and Clinical Excellence (NICE).

Although the campaign is progressing slower outside the United Kingdom, it is managing to get some traction internationally.

The World Association of Medical Editors (WAME), the South African Medical Research Council and the Canadian Agency for Drugs and Technology in Health have signed.

Maybe there is still hope this problem can be rectified.

Guest Post: Addictions and Development

Today's guest post is by Emma Haylett. She decribes growing up with an alcoholic father who literally tried to recruit her as his drinking buddy, and in the process put her smack dab in the middle (triangulation) of her parents' relationship. This may be a telling example of someone in the role of go-between.

A Revelation

My father bought me my first 6-pack of beer. I was only 14 at the time and drank it behind closed doors, away from him and the rest of my family. It was a late summer night and I remember my mother was already hidden away in her room, lights off, TV on such a low volume like she was whispering with ghosts. Dad sat in a broken recliner watching western violence, occasionally calling my name to come drink with him. Instead, I wrote. I started writing before I popped the first cap and continued to do so after all of them were empty and stagnant around me.

I knew the other kids at my school drank. I knew my dad drank. I watched him every day, but what I didn’t realize was the problem he held. Within the next two hours, I was dizzy and tired. The spoken words of my father were surrounded in quotation marks intermittently written down the page, phonetically spelled out: “Em-uhh,” “ehmm,” and “c’mon to the livin’ room, now.” 

As my state of clarity became more and more unclear, my dad’s stayed exactly the same. I didn’t know he was permanently inebriated until pouring over my notes the next morning. This revelation became something of an alcohol abuse study for years.

My mother never noticed the extra beer my father bought. I think she always assumed Dad was going to drink them, and it was a fair enough assumption. As he pressured me to drink them, I would sip slowly and watch him become more intolerable by the bottle. It didn’t taste good and I don’t remember it feeling good either. 

His speech slurred to the point of intelligibility and his breath was something similar to a laboratory experiment gone wrong. His actions embarrassed me – he would yell at the television if a star delivered a line poorly, and wrap his arm around my shoulder to tell me how to buy liquor underage. Whenever my mother entered the room, his face became tired and uninterested.

One evening, after Dad was snoring deeply in the chair, my mother sat me down and asked me if I drank with him. Of course I didn’t lie – I told her he would give me a few bottles and we would watch TV together. She told me Dad wasn’t healthy and that what he was drinking wasn’t, either. She told me he was always cracking cans since he was about my age, partying much too hard with his friends and family. I wasn’t old enough, she very sternly told me, “and your dad’s decisions reflect poorly upon this family.” I stopped drinking with him after that night.

Family Treatment

Dad was kinder in the early hours of the day and progressively became more incoherent and rude towards the time he usually passed out in the recliner. I come to realize, from lengthy trial-and-error experiments, that the trick to getting lunch money, permission to go out on school nights, or even a small favor was asking him in the mornings after his first coffee with a whiskey cream substitute. 

My mother took the opposite route and, when she thought I wasn’t around, suggested rehab programs later in the evenings, or else, she threatened, she would leave…again and again. But she never did. Their relationship became empty threats with the two of them screaming about whose turn it was to buy essential toiletries with the little money we had, and who was going to raise their daughter standing behind them unnoticed.

There was more hidden behind my father’s alcohol addiction than what was obvious: the empty bottles clacking together as he put another one down was always accompanied by false affection when we had father-daughter talks around the dining room table late at night about being a responsible adult, trust, and his image of love. I learned that being responsible was saving a bit of grocery money for a tall bottle of cheap alcohol. Trust was believing him when he said, “Just one more,” and love was “don’t tell your mother” followed by a bribe.  

Promises to attend my school-sponsored activities came to a screeching halt as the more dangerous drugs became the better part of him. I once found him asleep in the truck idling in the driveway with the windows down and a burnt cigarette between his still fingers. The long stem of ash flaked away as I shook him to remind him that he was supposed to take me to school.

Emotional Detox

I lied to my friends. I lied to my teachers, and I lied to myself - for years. It goes without saying that I don’t trust long or often. I had a hard time believing my ex-fiancé Jake was going for a quick run to the gas station without bringing home a brown paper sack around a bottle or plastic baggie of some substance. I am reminded of being alone when my new neighbor’s empty beer cans crash and echo against each other as she pushes her trash bins to the curb every Thursday morning. I am still angry at my mother who should have tried harder to get my father some help.

I always wished he would have even considered alcohol rehab. I firmly believe our family life could have been different, saved even, with detox and therapy. As an adult, I hesitate to show affection and honesty. I have daylight visions of my father wrecking the truck. I lose hours of sleep over the conversations I should have had with Jake about trust and what it means to be loved without stipulations.

Looking back, it’s hard to know what it is I was feeling. From adulthood, it is easy to know that my father was using me as a crutch, as a tool with which to hurt my mother. And I dutifully played the part of loyal daughter to both of them. I was a substitute, in many ways, for their relationship—an embodiment of the good in my father as my mother saw him, a (albeit young) drinker still capable of offering love - and so she ignored it. For my father, I was a female who served as his caretaker and confidant, a secret-keeper who acted without judgment, an enabler. While my father was dependent upon alcohol, I was simply (or not so simply) using it—more on that here. This was my first experience as an enabler too.

I do remember feeling trapped in between them and, because they were my parents equally, wanting to please both. If I could do it simultaneously, even in secret, it felt like a win. I didn’t like the taste or feel of alcohol, but I also didn’t like the way my father breathed my name until I came out. For me, this drinking was easier, especially since I never outright lied to my mother. Like my father, I had my justifications.

Therapy

I’ve learned that addiction is better treated as a disease. With a non 12-step program, doctors treat addicts with proper medical treatment as you would any other chronic medical illness. Working with addicts in this program has taught me that sometimes you can’t rely on having faith or attending self-help meetings. Sometimes real help (however you find useful to define it) is necessary. 

Addicts can come to an understanding of trust and commitment, as well as formulating a self-betterment plan that is supported by people like me. I provide the guidance and encouragement as well as sensitivity to the issue.

My father would always get upset if the word “addiction” was even quietly muttered.

I realize what it is like to be an addict. I watched and recorded one my entire life. To approach the issue with proper intelligence and caution is critical – to provide them with real courage and motivation rather than standing idly by will push the addict towards getting the appropriate help and the chance of staying healthy will greaten. It’s a very rewarding opportunity to be there for somebody and to see them succeed.

I help myself by helping people overcome these dangerous addictions. I help them make that sensitive reconnection to their family and children. There is always hope that they can raise their kids to live without being exposed to the fear and emotional emptiness that that I hold inside and that is so overwhelming. Getting help can change more than one life. That first step is always the hardest, but I know in my heart of hearts it can make a difference.

Author Bio: Emma Haylett finds comfort in writing. When she’s not helping coordinate non 12 step recovery programs for addicts and their families, you can find her watching terrible made-for-TV movies.

Part 5 of Dr. Allen's Discussion About Borderline Personality Disorder - The Earth Needs Rebels Show on Orion Talk Radio

Part 5 of my discussion of borderline personality disorder on Free Thinking Voice - The Earth Needs Rebels internet radio show was on live Tuesday, November 12, from 12-2 PM U.S. Central Time, and is now found on their website.    

Here is the link to the downloaded broadcast: http://oriontalkradio.com/archives.htm.  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, November 12, at 1:05 and 2:05 PM.

Themes of This Blog Seen In Newspaper Advice Columns – Part II

This is the second in series of posts showing how several of the issues I discuss in this blog show up in letters to newspaper advice columnists. Advice columnists must bring us problems that resonate with a fairly wide readership, and they therefore provide us with another source of information about human behavior and cultural trends.

I follow Jeanne Phillips (Dear Abby), Carolyn Hax, Amy Dickinson (Ask Amy), and Marcy Sugar & Kathy Mitchell (Annie’s Mailbox).

I will highlight each theme with a title preceding each letter to the columnist that I've reproduced, reflecting the blog subject that seems to be discussed. The title will also be a link to a related post. I am not including the columnist’s responses to the letters. 

"In relationships, if you always do what you always did, you'll always get what you always got." ~ Amy Dickinson.

Whenever a family member has somewhat compulsively behaved in a certain manner for a very long time, and then decides to change, the change often does not go over well with the rest of the family. The others seem determined to force the changer to go back to his or her old ways. 

In this post, I am emphasizing the above process rather than the particular role described in these letters, which I have not previously discussed directly as a separate entity. In the following three letters, the writers all had served in various incarnations of the same role, and complain about the reactions of the rest of their families when circumstances changed. The role might be called the “family support person,” or in a more extreme form, the “family servant” or even “the enabler.”

6/7/13.  Dear Carolyn: I’ve always been the one in my family to give whenever possible. When I went to college, I took on student loans so my sister wouldn’t have to. A few years later, when her car died, I purchased a new one and gave her mine. When family needed help, I was always there. Now I’m trying to purchase a house, and no one seems the least bit interested in helping me. I swallowed my pride and asked for financial assistance, even if it was a “loan,” and was told tough toenails. Would it be wrong for me to cut my family out of my life? I feel as if I was the great son whenever I went out of my way to help, but now I’m just some annoyance. - Always the Giver

6/18/13. Dear Amy: I've spent most of my life being a support system for various friends and relatives through one crisis or another. I've always been proud of the fact that I'm someone they can rely on when they need to. Recently, I learned that I may have a debilitating disease for which there is no cure. No firm diagnosis has been reached, but at this point it doesn't look great. Since I received the last batch of test results, I have witnessed my friends and relatives pull away from me, dismiss my symptoms and change the subject if I bring it up. I understand that everyone has their own lives and problems, but I desperately need some support right now. — Lost

June 24, 2013.  Dear Annie: My husband and I both work 18-hour days at a hospital. When we get home, we are exhausted. Since our schedules are irregular, however, our siblings seem to think it means we are always available for free babysitting. My husband's sister (a stay-at-home mom) is forever dropping off her toddler, saying she needs to "de-stress." She never calls ahead. We've tried locking the door, but she has a key. My brother has dropped off his young sons multiple times without warning and with no indication of when he'd be back. He stopped when I told him I was going to start charging him $12.50 an hour.  

The last straw was when my oldest brother's wife arrived one weekend in a van with seven little girls and stated that these kids were staying overnight with us because she and her girlfriend were going to a spa. I was just getting off a 24-hour shift, and I told her politely that since she hadn't checked with me beforehand, she'd have to make other arrangements because I was too exhausted to care for her girls and those of her friend. She became angry and told my nieces that I don't love them. Her girlfriend, whom I had never met, screamed at me from the passenger window. After they left, I got nasty phone calls from my brother and parents. The friend sent me an itemized bill and asked that I reimburse her for the spa trip they missed. Instead of responding, my husband and I sent our family members an email outlining that we love them and our nieces and nephews, but we would no longer be available for babysitting unless it was an emergency. We apologized for being rude or for causing them any trouble. The email was much kinder and more polite than they deserved, but we hoped it would allow us to start over. It was not received well. Currently, the only person speaking to us is my father-in-law. We considered moving in order to have boundaries, but I resent being forced out of a house I love.  I miss my family. What can we do? — Not the Nanny

Your Spouse’s Secret Mission 

Wherein one’s spouse plays the villain to take the heat off a husband or wife who cannot stand up to his or her own family.

8/19/12. Dear Annie: My daughter-in-law tends to go to her family. She says she is uncomfortable with my son's side. She has been rude to us since she married my son, and she controls him. She threatens him if he does not do what she wants. My daughter had a fight with my daughter-in-law four years ago, and I just woke up to the fact that my daughter-in-law blames us for my daughter's actions. My husband and I tried therapy with my son and daughter-in-law, but it made things worse. I left, saying that I am not happy with either of them and I just want to see my grandchildren. My son said that if I don't continue with therapy, I won't see the kids again. They are using the children as weapons to control us. I told her she didn't like us from Day One. She told me she doesn't trust me. My new granddaughter had a baptism, and my daughter-in-law told us it was an occasion only for her family. We were insulted and hurt. I'm thinking of going to court and suing for grandparents' rights. — Trustworthy

Tag, you’re it 

Despite the protestations of heritability study authors across the universe, parents do not treat all of their children the same.

9/21/13.  Dear Annie: I'd like to add my two cents about whether parents treat their children the same. Mom, Sis and I live equidistant from one another. Sis still lives near the place where we grew up. Mom moved to a warmer climate. We call each other every weekend to catch up and stay in touch. Sis and I fly to visit Mom about once a year. Mom visits Sis and her family a few times a year. But despite the many invitations I have extended, she will not visit me. When I had heart surgery five years ago, Mom did not come. When I was hospitalized for pancreatitis, Mom did not come. Of the 25 stage plays I've appeared in, Mom came to see exactly one. She will never see the home my wife and I remodeled. It seems the things that are important to me don't matter much to her. I suppose there is a certain amount of validity in her excuse that there's nothing that interests her in my city, but when we visit our son and his family, we don't care whether there is anything to do. We are simply glad to be with them. Does Mom love me? Certainly. Does she love me as much as my sister? Probably. Does she treat us the same? Judge for yourself. — That's My Lot in Life

Guest Post: Breaking Free of Being the Perfect Child

Today's guest post is by Paul Taylor. This is the fourth post in which a writer recounts his or her own experience in a family with a problematic history, as well as its aftermath. It illustrates a couple of themes of my blog very well: a family role that must be played by a member – or else - and the existential horror and despondency people feel when they try to break away from it. His criticism of cognitive psychotherapy for this sort of problem is also right on.

It is hard being the perfect child. According to my family, I was born perfect. I was quiet and obedient and always willing to help out. From the time I was very small my family relied on me to be the good, responsible child. Although I was not too much older than my siblings and cousins I was relied on to make sure they were safe, happy, and cooperative too.

As I got older and some of the extended family moved away my responsibilities changed. I was now supposed to go to school and do all my work without complaint or question, answering any inquires about what I was learning with an in depth explanation. Then I was supposed to help my younger brother complete his school work while also teaching him what he missed in class due to his ADD. After that came helping with chores like ironing, laundry, dishes, yard work, vacuuming etc. That I was also supposed to do without complaint for as long as it took. 

Every member of the family had set chores and I was expected to not only do mine, as quickly and quietly as possible, but also “help out” with everyone else’s. That meant doing the dirtiest, hardest or most complex jobs while they watched and shook their heads –feeling helplessly confused all the while.

If I finished everything I was then expected to have “family time” which consisted of sitting around the television, watching something my brother and I were not interested in. I was supposed to keep him quietly entertained so we could “be a family.” If, by chance, there was time left over before bed I snuck in reading a chapter or two of my books, which were my only escape from reality.

When I got into my teen years and nothing changed, I began to become uncomfortable with the arrangement. 

I had not made many friends outside of school before then, of course, due to my packed schedule. When I attempted to make plans with friends and let my family know ahead of time, some emergency inevitably came up: a last minute project, a chore that had to be done RIGHT NOW, or just a guilt trip of “not being with your family.”After a few attempts I decided it was not worth the effort and went back to my routine.

Finally when I reached my twenties I realized that my life style was not normal. I started to try to pull away. I knew that I wanted to become my own person and not just the person they told me I was. I wanted to make choices based on my own needs and desires instead of doing what would make them happy or what would not get me in trouble with my family. It was very hard for me to break out of the thinking patterns that had formed from my many years as the perfect child. 

I constantly had to remind myself that I was not responsible for anyone else’s happiness or emotional welfare. I could not change anyone no matter how much I did for them or how much I loved them. In fact I was only allowing them to continue to suffer because they never had to grow as long as I picked up their slack.

At first I planned to move out. I started to squirrel away money for an apartment and shopped around near my work during lunch to see what I could afford. Then a few weeks before I decided I would make my move, a family member had to have emergency surgery.

Well, of course I couldn’t leave then. There was an actual sick person to take care of; the house had one less person to help with clean up, and the person that did not work and stayed home needed a break in the evenings. It was only reasonable.

Six months went by and I decided that I would take a smaller step towards being independent. I planned on going on a trip by myself for two weeks. I would use the money I had saved to pay for the gas, and I had a tent so I could just go on a road trip and camp along the way. I got permission from my work and was all ready to go. I decided to give my family two weeks’ notice so that they could adjust to the idea.

Bad idea.

As I started to pull away, my family teamed up against me. From telling me I was wrong in my thinking to guilt trips to outright anger and abuse, they piled on the difficulties and tried to make me conform to their way of thinking; the way that was easiest for them. I fought back for a while but eventually got worn out, and found myself being sucked back in.

I postponed my trip indefinitely.

However, this time I was aware of what was going on around me. I felt like I was living in another world. I watched in horror as I went through the same day-to-day routine of being the perfect child and cleaning up the messes they left behind. I felt disconnected from reality and just went through my days with a kind of hopeless, formless, pointless movement. Somehow I thought that as long as my body was moving I was still all right and functioning.

What I did not realize is that I had become seriously depressed. I had been depressed in the past but had repressed the dark times in my life to the point where I did not even remember them happening. I tried to function on auto-pilot without my own conscious approval. However, this time around the auto pilot would not engage. I had become too self-aware to let my brain slip into a waking coma.

It got to the point where I would be driving and would consider just letting go of the wheel and seeing what happened. After all, it did not matter one way or the other. What was the point of living like this?

After having several similar thoughts, I sought professional help. Although it did help to have my irrational thinking pointed out to me, it did not help in the sense of giving me something concrete to do.

“Move out,” they said, “Get away.”

Well, that is all well and good for someone to say, but the practicality of it was beyond me. I had been beaten down by the combined forces of my family. From bills to pay to broken down cars to guilt trips and attacks of hysteria I had so much to deal with that even planning a way out was beyond me.

I checked out. I really did. I went to work every day and somehow managed to crank out my job with no brain power. I got home and took care of the chores and bills and things that needed to be done. I chatted pleasantly about the weather, feigned listening attentively to problems, and worked steadily until it was time to fall into bed and start the whole day over again.

Weekends and weekdays were indistinguishable except for the physical activity required. It was much more restful at work, sitting at a desk, then at home running errands, cleaning up messes, and trying to pretend everything was fine.

Hopeless does not even begin to describe it.

I tried to express to my family why I was so angry, or stressed, or just listless. Their solution:

“Just stop thinking so much. Everything will work out.”

Eventually I got fed up with the whole thing. Working with friends I came up with a way to get out of the house. One day I just moved, taking only a couple of bags of clothes and tossing them in the trunk of my car I left.

After the meltdown, things changed. I was still the ‘perfect child’ in some ways but I learned the benefits of boundaries and getting away from people. The physical distance helped me to create a personal space where I could feel safe and grow. It was still very hard for a long time but it has gradually gotten better. My family still attempts guilt trips and manipulation but now that I have time to see things as they really are I can resist them and deal with them in a healthier way.

Author Bio:

Paul Taylor started www.babysittingjobs.com which offers an aggregated look at those sites to help families find sitters and to help sitters find families easier than ever. He loves writing, with the help of his wife. He has contributed quality articles for different blogs & websites.

Docs and Drug Reps

If you’ve been to a doctor’s office any time recently, you’ve probably seen them.  Nicely dressed in suits or pant suits.  Dragging their little bags that look like the carry-ons with wheels you see at airports.  Mostly nice looking and young, male or female. Patiently waiting for the office staff to call them to come in the back.

You don’t generally see what’s going on in the back with them, but these are the drug reps.  The detailers.  The pharmaceutical company salesmen.  They used to bring assorted gifts to the office like pens and other paraphernalia with drug logos on them, but now they mostly come bearing drug samples and lunch.  Due to a recent change in the law, doctors have to “report” any such favors into a database, but hardly anyone looks at it.

The drug reps are there to tell the docs about their latest products. They have to stick to the information approved by the Federal Drug Administration. The doctors certainly need to hear about the newest medications. So what’s the harm?

Well, potentially, plenty.  Most “new” drugs do pretty much the same thing as old established drugs.  Sometimes they have different side effects, some of which are better for the patient and some of which are in fact worse.  Being under patent, they are of course way more expensive than generic drugs which are often just as good or just as tolerable.

As readers of this blog know, the drug companies have been studying the psychology of doctors for decades, and have developed a lot of tricks and misleading tactics to increase sales of their brand named drugs. These techniques are quite powerful, and many doctors do not understand how they are being manipulated, sometimes to the significant detriment of their patients.

As a critic of these marketing techniques, I belong to a group called “Healthy Skepticism.”  Many members of this group argue that doctors should have NO contact at all with drug companies in any form whatsoever. They point to the fact that most doctors think they are not being unduly influenced, and yet believe that most of their colleagues are! The high sales of brand named drugs when generics are available prove, they go on, that no doctor is immune to pharmaceutical marketing tactics. So therefore drug reps are the enemy.

You think I would agree, but I do not. Just because a lot of doctors think they are not being influenced but actually are does not mean that some doctors believe they are not being unduly influenced, and in fact are not. Not everybody kids themselves. It is true that everyone is influenced by others to some degree. So by that reasoning doctors should avoid talking to members of Healthy Skepticism, because then they will be unfairly influenced against the drug companies.

How are we really going to understand misleading marketing techniques if we never personally witness them? How do we keep our eye on Pharma if we are averting our eyes?

Also, there’s that troublesome little fact that we live in a capitalist country, and if capitalists are properly regulated, that’s a good thing.  While I believe deceptive advertising should of course be stopped far more effectively than it has been, I nonetheless do believe in the company’s right to portray their products to physicians in the best light.

Also, when a new drug first comes out, the drug rep may actually be a good if not the only source of information - provided the doctor listens with a critical  ear.  

As Carolyn Rabinowitz, former president of the American Psychiatric Association, was quoted as saying in the September 20, 2013 issue of Psychiatric News, “Drug Companies perform a useful function, and they must make money or they won’t invest in our field." 

I do not blame the drug companies for misleading doctors as much as I blame the doctors for not knowing when they are being misled.

Adriane Fugh-Berman, M.D.

Sanita Sah and Adriane Fugh-Berman of Georgetown University, the leaders of industry watchdog Pharmed Out, recently pointed out in the same article that if doctors know and understand their marketing techniques, then they are in a fairly good position to see what they are doing and to not be taken in. 

Maybe I’m kidding myself, but I let the reps buy me lunch, and yet I still almost never prescribe brand-named psychiatric drugs unless a patient does not respond to, or is completely unable to tolerate, generic drugs in the same class. And so called “diagnostic inflation,” so that everyone seems to need a drug – well readers of this blog know how I feel about that.

For most of the time that I was the director of a psychiatric residency training program, the drug reps provided lunch for the residents at certain classes and for "journal club." The reps were allowed to give the residents a short sales pitch for one of their new drugs, and then they would leave leave the room. After the reps left, I  would critique what they said and point out any exaggerations or misleading information. That way, hopefully, these future psychiatrists would learn to be wary consumers of this type of information.

Now, the drug reps have been banned from providing lunch for the residents, so the residents no longer get this valuable training. When they graduate, they will be less able to resist a sales pitch, not more able. Bad idea.

The biggest psychological trick that drug reps use is taking advantage of our natural tendency towards reciprocity. You do something for me, and I feel obligated to do something for you. It’s not the pen or the pizza, it’s the relationship with the person who brings you those things.

Drug reps are hired more for their likeability and social skills than anything else. As the article states, “And flattery, whether it’s a pleasant conversation over the archetypal pizza or an invitation to speak at a prestigious meeting, gets them everywhere.”

Doctors need to learn this, but most have not. There oughta be a course in medical school about his. Forewarned is forearmed.

Book Review: "The Secrets They Kept." The Power of Family Secrets

In my post of June 18, 2013, The Historical Backdrop of Family Dysfunction, I reviewed Deborah Cohen’s fascinating book, Family Secrets, about the cultural forces and historical events in England that generated secrets within families. 

One of the themes of this blog is that the development of secrets within a family can have devastating effects on family relationships, literally over many generations. An excellent example of this is described in a short but beautifully written book by  Suzanne Handler called The Secrets They Kept: the True Story of a Mercy Killing that Shocked a Town and Shamed a Family.

The secret had a highly negative and significant effect on the relationship between the writer and her mother.  When the author learned of it, suddenly much of her own behavior, as well as that of her mother, made a lot more sense.  I find this happens with my patients in therapy. For generating true and lasting behavior change, it is almost always more important that patients gain insight into their family dynamics than it is for them to gain insight (a la psychoanalysis) into themselves.

In this case, cultural and societal attitudes towards, and the treatment of, the seriously mentally ill was a prime factor in both the formerly secret event as well as its aftermath.

Suzanne Handler

When her own son was graduating from college, the writer was suddenly told about the secret by an aunt through marriage. The aunt had promised the patient’s uncle that she would never tell, but the uncle had died. Learning about the secret shocked Ms. Handler to her core. 

She learned that her maternal grandfather, a man she had always had warm feeling for, had killed one of his own daughters, and then tried unsuccessfully to kill himself.

The date was August 16, 1937.  The place was Cheyenne, Wyoming. The cultural group was an Orthodox Russian Jewish Community.  They had found themselves in this somewhat strange place because their group had been diverted to Wyoming from the usual immigrant placements on the East Coast by a Jewish organization.  The mental illnesss of the then 16 year old sister, Sally, had been called “dementia praecox” by the local doctor – an illness now known as schizophrenia.

The girl was on the verge of being committed to the main state mental hospital after two suicide attempts, one of which involved trying to burn down the family’s home. Both the grandfather and this aunt knew what was in store for her at the state hospital. 1937 was in the days before antipsychotic medication, and a commitment was basically a life sentence. And certainly not something to look forward to.

Although the author, who is a journalist, was unable to find descriptions of the hospital milieu at this particular facility during the relevant time period, in general the treatment of the mentally ill in most state institutions was ghastly. This in spite of the efforts of crusaders like Dorthea Dix and Nellie Bly. In institutions across the United States, inmates were often left filthy and naked, given almost inedible food, frequently beaten by the hospital staff staff, and experimented upon with various “treatments” which could be nothing short of barbaric.

Apparently with no way out, Sally begged her father to kill her. When he initially refused, they decided to arrange a suicide pact.  After shooting the girl, her father shot himself twice and then stabbed himself - but somehow lived.

He never served any jail time, however. The prosecutor took note of the unusual circumstances of the murder and agreed that he was unlikely to harm anyone else ever again. He was given a suspended sentence and probation.

After learning of the family secret, the author set out to find out more about what had happened.  The story had been all over the local newspapers at the time, but little was said there about how the family fared after the trial. There were only two living people who were alive at the time of the incident and who could shed light on that – the patient’s mother and her youngest brother, and they were not talking.

Their responses were telling. Mother at first said, “I never want to read or talk about this again.” (Later she did relent just a little and revealed some minor tidbits over the years).  The patient’s uncle was even more closed off. He, “…turned to me, and in a voice that was ice-cold and laced with anger, he muttered under his breath: “Don’t ask me about Sally again. I will never discuss her. Not now and not ever!” (p. 43).

What could possibly account for this conspiracy of silence, especially since all of the other parties directly involved were deceased?  Certainly the shame the entire family must have felt in their tightly-knit minority community had been staggering. There were a number of reasons for this. First of all, no one at the time understood mental illness, and there were all sorts of very negative cultural myths about it.  

Second, Jewish law and ethics forbid both euthanasia and assisted suicide.

Third, and perhaps most important, because of their history in Russia of being a hated and persecuted minority, this community’s mindset was to keep a low profile whenever possible. Their philosophy was to do nothing to bring on negative criticism or trouble. 

This particular family had already brought shame to themselves in the eyes of their community because shortly before the killing, the mother’s oldest sister had done the unthinkable.  She had married a gentile. In response, the family “sat shiva” for her – a ritual used to mourn the death of a family member.

Soon after the grandfather's sentence was handed down, the whole family pulled up roots and moved to California. The writer’s mother married her high school sweetheart, the writer’s father, only four days after the trial ended and headed for California the very next day - dining on foods prohibited by kosher law all through the trip! They may have had to marry quickly because, according to a widely circulated rumor, the shame on the family was about to lead to the writer’s father being prohibited from marrying Mom by his own family. 

In her entire life, the mother went back to Cheyenne only once.

The writer’s descriptions of her grandmother, Sally’s mother, were also very telling. She lived out her days totally devoid of expression. She often sat staring out her favorite window, never answering a door or making a phone call to the writer’s knowledge, and not keeping house well.  (There was some indication that the community from which she came had thought her odd even before the killing).

The effect of all these events on the relationship between the author as a child and her mother was chilling: She “...did not, could not connect with my mother. When she looked at me, I thought I saw disapproval and disappointment reflected in her eyes. I felt unwelcome, a stranger in my own home.”  

Mother seemed uninterested in her. Moreover, Mom’s days seemed joyless, as if she were prohibited from enjoying herself. This attitude rubbed off on the author.

As anyone faced by inexplicable parental behavior would when there is no obvious explanation for it, the writer “...made all my assumptions [about her mother] based on ignorance.” She naturally felt that her mother did not seem to like or want her.  How could she know that her mother may have felt guilty that she had not been able to protect her younger sister? That had actually been her job when Sally was being teased at school because of her odd behavior and dark complexion. 

It also seems likely that grandma became quite depressed, and she clearly had difficulties relating to her own daughter, the writer's mother.

Because of the stonewalling about the incident by the living, the author’s inquiries into the events often raised more questions than they answered. This was also a bit of a frustration for me as I read it, but I am certain that my frustration was absolutely nothing compared to that of the author’s.  

Truly a spellbinding story.