Sunday, January 26, 2014

Conflicts of Interest

The following story was recounted to me by someone who was there:
He was indignant. Outraged, even. He was a department chair. A prominent psychiatrist and author of textbooks. A Key Opinion Leader in the field. How dare the New York Times question him?

The psychiatry residents sat in silence as he went on his rant. Every other medical specialty does the same thing! How come they didn't go after the orthopedic surgeons or the cardiologists, who made much more money from industry relationships than psychiatrists? They went after psychiatry and psychiatrists because of the stigma surrounding mental health. And what is this whole conflict of interest business, anyway? The New York Times even had an article on Michelle Obama's clothing retailer having a conflict of interest. 
It's ridiculous! And the senator who started all this, Senator Grassley? What about all of his campaign contributions? Does he have conflicts of interest?
He had more choice words for the Times and for Senator Grassley, but you get the idea. His mindset seemed to be that because what he was doing would ultimately help patients, he was beyond reproach as long as he was not committing any crimes. Since funding was limited, what was wrong with working with industry? When all the other specialities make more than psychiatrists, why shouldn't psychiatrists take part in entrepreneurial activities?

Not surprisingly, he is no longer the department chair. However, five years later, this mindset about conflicts of interest still remains with some (many?) of psychiatry's leaders. How else to explain the recent revelations about David Kupfer, chair of the DSM-5 task force? He failed to disclose that he was part of a company making a dimensional assessment for depression, both during the DSM-5 process and on an article that he co-authored with his business partner, statistician Dr. Robert Gibbons, who seems to be creating a commercial product with public money.

The ends do not justify the means. Just because someone else is doing it doesn't make it right. These may be rote lessons from childhood, but it seems that some people have conveniently forgotten them. In my opinion, this most likely happens not because of greed, but when people truly believe that they are doing good; therefore they must be good, and their critics must be bad. Narcissism is a powerful and dangerous thing.

Monday, January 20, 2014

The Risks to Adolescents of Legalizing Marijuana

2014 is a banner year for proponents of marijuana legalization, with cannabis becoming legal in Colorado and Washington state. The upcoming Super Bowl will go down in history as the Marijuana Bowl. Even President Obama has weighed in, saying in a New Yorker profile that he believes marijuana is less dangerous than alcohol "in terms of its impact on the individual consumer."

I acknowledge that there are probably going to be societal benefits to decriminalizing cannabis. Fewer people would be locked up on minor drug charges, police departments can devote their resources elsewhere, and there would be higher revenues for states. I also believe that most adults can smoke weed responsibly without abusing the privilege.

However, what I don't see mentioned much in the popular press is the deleterious effect of marijuana on adolescent brains, and how the drug could fundamentally alter a young person's life. As a psychiatric resident working in a university hospital ER, I saw a slew of college students who became extremely paranoid and had disturbing hallucinations after taking just a few hits of marijuana. At first, I and some of the other doctors thought that their weed had to have been laced with amphetamines, but all of their urine tests came back positive only for THC's. Since I've completed my training, I have seen numerous people in their late teens and early 20's with no family history of schizophrenia, who became very psychotic after months or years of regular cannabis use. Sadly, the psychosis does not always go away even after they stop smoking.

For the past decade, there has been convincing evidence that cannabis use is correlated with higher rates of psychosis. What was not clear was whether this correlation meant causation, as it was also plausible that people who go on to develop psychosis like to use cannabis to self-medicate. However, study after study has now shown that people who use cannabis earlier in adolescence (or use more of it) also develop psychosis earlier, with the same effect not being true for alcohol or tobacco, strongly implying that cannabis causes psychosis.

One of the latest studies, published in December 2013, had the following results:
The prevalence of psychosis and schizotypal personality disorder increased significantly with greater cannabis use in a dose-dependent manner. The associations between cannabis use and psychosis were 1.27 (95% CI 1.03-1.57) for lifetime cannabis use, 1.79 (95% CI 1.35-2.38) for lifetime cannabis abuse, and 3.69 (95% CI 2.49-5.47) for lifetime cannabis dependence. There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner.
Even if the worst-case scenario of psychosis does not occur, there's the potential for other harmful outcomes. I have had patients who became physically dependent on cannabis to the extent that they felt nauseated and could not keep food down unless they have smoked. Not surprisingly, cannabis use also appears to be correlated with lower educational attainment, especially for those who started using before age 15.

Already, even before it had been legalized anywhere, there were some unsettling trends among teenagers when it comes to marijuana. The good news is that teenage use of alcohol, tobacco, and most illicit substances is trending down. However, use of marijuana has steadily increased in recent years, such that it is now the second-most abused substance after alcohol. Teens are also increasingly perceiving marijuana as being not so risky, with the percentage of 12th graders who see regular marijuana use as posing "great risk" decreasing from about 56% to 42% between 2006 ad 2012. And now, with the legalization of cannabis in some states and comments like those from our President, the perceived risk will only continue to decrease.

What are the societal and ethical implications of this? Perhaps marijuana is safer for most people than alcohol or tobacco. But for those who are susceptible to the psychosis-inducing effects of marijuana, its effects can be horrendous. Is it acceptable to permanently mess up some people's minds for the enjoyment of many? Strange how this is starting to sound like the NFL and the concussion issue. In the New Yorker interview, Obama had this to say about pro football and concussions:
"At this point, there’s a little bit of caveat emptor," he went on. "These guys, they know what they’re doing. They know what they’re buying into. It is no longer a secret. It’s sort of the feeling I have about smokers, you know?"
Do all these young people who are regularly using marijuana have a similarly informed view of what they're buying into?