Archive for April, 2010
In another case of pharmaceutical giants taking part in what has become a convoluted pay-to-promote plan, AstraZeneca is set to pay a $520 million settlement as the result of a federal investigation revolving around their off label marketing of Seroquel. That sounds like a lot of money until you realize they made nearly 5 billion off of the drug in 2009 alone. That makes the settlement look a lot more like paying a toll than a hefty fine and still raises the question, When (if ever) will convictions start coming down?
From the NY Times:
“AstraZeneca paid kickbacks to doctors as part of an illegal scheme to market drugs for unapproved uses,”Kathleen Sebelius, secretary of health and human services, said at the event in Washington. She said the company promoted drugs for unapproved uses by children, the elderly, veterans and prisoners.
Glenn Engelmann, AstraZeneca’s U.S. general counsel, released a statement saying the company denies the allegations but settled the investigation with the payment.
“It is in the best interest of AstraZeneca to resolve these matters and to move forward with our business of discovering and developing important, life-changing medicines — while avoiding the delay, uncertainty, and expense of protracted litigation,” Mr. Engelmann said.
If companies’ sidestepping safety measures and paying doctors to disregard patient safety is going to continue to be treated not as a crime but an indiscretion, there is little hope for a turnaround in any foreseeable future. It’s a bad step made worse by the fact that they’ve targeted some of the most at-risk and vulnerable among us. Children, elderly, veterans and prisoners are all left with little choice but to take the drugs they’re given whether the perceived need is determined by medical inquiry or financial gain on the part of the doctor.
Of course it’s in the company’s best interests to deny the allegations and pay the toll. The alternative, in theory and on paper, is to go down the road of criminal litigation. Patient safety be damned, there’s money to be made and if a conviction resulting from “protracted litigation” can exclude companies from government programs like Medicaid, then the best option for them will always be to pay these small settlements.
As a result of aggressive marketing, Seroquel has been increasingly used for children and elderly people for indications not approved by the Food and Drug Administration. The drugs have caused rapid weight gain in children, and side effects including deaths have prompted warnings against giving the drugs to elderly patients for dementia.
According to company e-mail messages unsealed in civil lawsuits, AstraZeneca “buried” — a manager’s term — a 1997 study that showed Seroquel users gained 11 pounds a year, while publicizing a study that asserted users lost weight. Company e-mail messages also refer to doing a “great smoke-and-mirrors job” on unfavorable studies.
Warnings and small fines are not going to save lives or turn the tide of corruption in marketing and medicine, they will only serve as a payment of a toll and an acknowledgement of roles without consequence. If their actions are criminal and dangerous — and they clearly are — then they should be treated as such. Maybe we can start with actually prosecuting for their off label marketing and doctor kickbacks — or better yet, a few hundred thousand counts of reckless endangerment.
Like all of the major pharmaceutical companies, Pfizer has a history of misconduct, corruption and deceipt but when is enough really enough? They were overdosing children on Geodon in clinical trials marked by almost every kind of failure and misstep. It’s okay though, they got…(gasp!)…a warning.
Among those controversies: Discredited doctors allegedly prepared research on Geodon for the FDA; Pfizer allegedly promoted the drug for unapproved uses in kids; and the company allegedly paid a non-profit mental health advocacy group to promote Geodon for kids.
The FDA warned Pfizer that its trials of Geodon in children were improperly monitored, and that children got too much drug by mistake:
… dosing errors occurred and overdosing extended over several days for all seven pediatric subjects; in one case for as long as 22 days.
…a Pfizer internal document dated October 3, 2007 and entitled “Safety Information on Affected Subjects” refers to the overdosing of an additional six pediatric subjects in study (b)(4) at two different sites…
The kids suffered from nervous tics and a loss of control of their limbs, among other symptoms. Pfizer said it conducts tests globally according to the highest ethical and scientific standards:
HIghest ethical and scientific standards? I would love to know what passes for standards at Pfizer because from where I’m sitting, it’s hard to recognize any. They’re treating children like guinea pigs — and poorly treated ones at that.
Of course the company responded in the industry’s typical own-up-to-it-and-say-you’re-trying fashion with a letter that reads like the kind we were made to write as schoolchildren about how we understood it was wrong to disrupt the class or make messes.
Pfizer recognizes the seriousness of the issues cited by the FDA and is committed to fully addressing FDA’s concerns. Many of the items cited by the FDA were first uncovered and reported to the FDA by Pfizer as far back as four years ago as part of our ongoing clinical trial monitoring and quality assurance processes. Since that time, Pfizer has instituted several new measures designed to improve monitoring and execution of clinical trials, including our oversight of clinical investigators.
Pfizer has communicated with the FDA about our conduct of clinical trials and, over the next two weeks, will provide an outline of new and existing processes for preventing similar issues with Pfizer clinical trials in the future.
It just sounds like more talk about writing up new policies of the type they’ve already proven to be capable of sticking to. I guess when it takes the FDA five years to get around to giving you a warning when you’re abusing children with drugs, the sense of urgency kind of goes out the window, doesn’t it?
If the dosing wasn’t enough, it would appear as though their application for Geodon use in children was “intentionally misleading regarding its cardiovascular effects.” On top of that they were accused by the DOJ of marketing off label (but then who doesn’t these days?) and stated in a DOJ statement:
The government alleges that Pfizer also promoted Geodon for use by unapproved patients, including pediatric and adolescent patients, and promoted Geodon for higher dosages than were approved by the FDA. This conduct included direct promotion by Pfizer sales representatives and promotion through the hiring of physicians, or “key opinion leaders”, to give promotional talks to other physicians about unapproved uses and dosages of Geodon. Specifically, these talks included encouraging doctors to prescribe the drug for children, and to prescribe the drug at substantially higher than approved dosages.
There is a lot of money in the sale of antipsychotics, particularly among children, a captive market that seldom has the option of saying no to the drugs. Pfizer pays a lot of money to doctors and other promotional outlets for one simple reason. They stand to make a lot more. They’re paying millions to make billions. Doctors selling other doctors on off label drugging and groups like NAMI promoting the notion to the patients for which they claim to advocate affords the company a kind of sales force that even the slickest of television and print ad campaigns can’t match.
One doctor was paid $4,000 a day to fly his private helicopter to meetings where he promoted Geodon off-label, according to a separate whistleblower suit, which Pfizer also settled.
And Pfizer allegedly gave more than $1.3 million in funds to the National Alliance for the Mentally Ill, a non-profit advocacy group, and hired the president of the organization as a paid speaker, according to another whistleblower suit. In an amazing coincidence, NAMI published a web page which advocated off-label use of Geodon in children.
So when is enough enough? if a company (really an industry) can lie about health risks, experiment on children, abandon ethical and scientific standards and engage in all manner of misconduct — what is too much? Why does it seem that all issues relating to pharmaceuticals and mental health seem to be relegated to smaller outlets of information and opinion put out by people who already have a position on one side or the other? Openly corrupt companies overdosing kids is not a special interest piece specific to mental health but a statement on our mistreatment of our nation’s youth regardless of the methods. I guess it’s easy to quell the outrage now that a warning from the FDA has set everything right again.
The controversial Dr. Kifuji, prescribing psychiatrist for Rebecca Riley, appears to have evaded any criminal responsibility by exchanging her testimony for immunity. She is, however, up against a malpractice suit and some of the things that have come up are startling in terms of just how Rebecca’s very early death transpired and the role Kifuji played in all of it. I know I’ve brought up the doctor’s role in this before but every new fact that comes out is more frightening and infuriating than the last.
The Patriot Ledger ran an article that covers many of the almost too-bad-to-be-true circumstances that point to the fact that if Rebecca and Dr. Kifuji had never met, Rebecca might still be here. Regardless of your opinions on children and drugs, this case was wrong all around and the result of at least three people’s indefensible actions. Kifuji was more a drug dealer than a psychiatrist and while that’s not particularly uncommon, the young ages of her patients makes her a standout, even among the over-drugging crowd and the predictable end result in Rebecca’s case shows her to be both reckless and ill qualified.
From the Patriot Ledger article:
Years before she became a board-certified psychiatrist, Dr. Kayoko Kifuji was diagnosing children as young as 2 as bipolar and hyperactive – and prescribing powerful cocktails of mood-altering drugs to quiet them.
By the time Kifuji finally passed the psychiatric board exam – on her fourth try – one of her youngest patients, Rebecca Riley, had a little more than a year to live.
The lack of involvement on Kifuji’s part was shocking. She saw Rebecca primarily for twenty minute sessions to adjust doses. Often she just used these sessions to put on paper her approval for the adjustments her mother was already making, having increased doses on her own and experimented with drug cocktails using drugs prescribed (also by Kifuji) to Rebecca’s siblings.
She relied almost exclusively on what Carolyn told her about the kids when diagnosing them and ordering increasing amounts of drugs for them.
Kifuji also trusted the mother to keep tabs on Rebecca’s heart rate and blood pressure for signs of problems with the four drugs she was on. Kifuji, a pediatrician who later became a psychiatrist, told Novotny during the deposition that she didn’t realize she had a blood pressure cuff in her office and could check the girl’s vital signs herself until after Rebecca was dead. She said she didn’t take Rebecca’s pulse with her fingers because Carolyn Riley told her the child’s pulse “was within normal range.”
Even a well intentioned mother shouldn’t be solely in charge of monitoring a child’s heart rate and blood pressure let alone a woman hell bent on gaining access to more and stronger drugs at the expense of her daughter’s health. Also, any pediatrician turned psychiatrist should think of performing such simple tasks as second nature. If not that, then what is a doctor for? How do you not even know you have basic medical equipment in your office? How does a doctor fail to check a child’s pulse? Oh, that’s right — her mother said. If that’s all there is to doctoring, it’s no wonder some might see her as just a drug dispenser. They can do the rest at home, it’s a mere technicality that you must be licensed to prescribe.
- Asked why she didn’t report Carolyn Riley to child welfare authorities after learning that the mother had increased the children’s doses at least twice without checking with her first, Kifuji said: “I just can’t report to the DSS. I need to … my role is to work with the parent and not judging them.”
- Asked if she ever told Carolyn not to give Rebecca cold medicine on top of all the drugs the child was on, Kifuji says no, “but it’s because Rebecca didn’t get sick, and I was never asked ”
Right — let a mother chemically abuse and experiment on a child but whatever you do, don’t judge and certainly don’t give them any more information than they asked for. The article goes on to point out other times that Kifuji refilled prescriptions before they should have run out, never asking for an explanation, just dishing out more and more drugs.
She prescribed clonidine – the drug that killed Rebecca – during the child’s first visit to control the “impulsivity” that Carolyn Riley described. Rebecca was 2 at the time.
Impulsivity at two hardly makes a child a psychiatric oddity but when you look at some of her notes regarding Rebecca’s apparently troubling behavior it’s easy to get the notion that Kifuji sees childhood as a disorder unto itself.
“Then consistently hyper all the time. Climbs up to top of jungle gym without any fears and thinking. Gets into everything. Just walk up to someone and smack them. Never gets aggressive. Hits kicks and spits when she’s being disciplined and laughs. Started to say things scared her. Whines and fusses a lot.”
Kifuji described the toddler as dysarthric, meaning she could not properly pronounce some words.
“A bit tired since yesterday. Coming down on flu. Fine as long as she takes clonidine. Sleeps throughout. Without clonidine gets very hyper and impulsive.”
“Climbs up on top of bureau. Tantrums or sobbing when she was told to clean up her toys” and “she wasn’t listening to her mother.”
This child was drugged for one reason — she was stricken with a case of toddlerhood. Dr. Kifuji seems to see no distinction between behavior and disease. Now that psychiatry has largely gotten away from talk therapy, we’re supposed to see psychiatrists as doctors of the brain — linking behavior to dysfunction in the brain. If that’s the case, Kifuji doesn’t make it very well. She’s like a mad scientist but without the science.
She explained that some researchers believe the area of the brain called the amygdala is different in people with bipolar disease. But she admitted she didn’t know where the amygdala is in the brain.
Of course you don’t need to know the brain at all to dispense drugs in the manner that Kifuji had begun making a career of (there is a timeline of Rebecca’s “treatment” at the bottom of the article). You only need to know that if you sedate a child enough, you can drug the behavior out of them. Sure, that child may be a “floppy doll” sitting in the corner but a quiet floppy doll and certainly not disruptive and if enough people will pay you to drug the childhood out of their children to one extent or another, then you’re in business.
Yes, the parents physically gave the drugs to Rebecca but they were used as a weapon and that weapon was provided by Dr. Kifuji. If she had given them a blackjack instead and told them how many times you have to hit a kid for effective behavioral treatment, this would be a different case entirely. Our view of prescribed medicine as care makes us resistant to the notion that drugs can be poison but they clearly can be and often are, particularly with psych drugs. When this happens, we need to respond accordingly.
There are no less than three guilty parties here in a case of chemical assault that ended in a child’s death. It’s bad enough that Dr. Kifuji was granted immunity making it impossible to hold her criminally accountable, even as more facts come to light pointing to her role not in anything resembling care but in a death. If she is not held civilly and professionally accountable, we’re saying her actions are acceptable, even desirable and we’re signing off on a prescription for some seriously detrimental treatment. I’m relieved to see she’s at least going to be made to answer for her actions. She’s certainly got a lot to answer for in this suit. Now we’ll have to wait and see what passes as accountability these days.
As some may have noticed, things come in waves around here. I’ve been very busy in recent weeks and I have not been able to post with the frequency I would like. I’m still paying attention and SB&F is not losing steam. I offer you two links that are very much worth following up on.
Pfizer: Too Big to Nail?: A giant among pharmaceutical companies, Pfizer has skirted the law in a big way on the basis of its size alone — and their friends in the FDA are happy to help. When they were found guilty of marketing a drug off label without regard for patient safety, they should have been convicted. but…
Promoting drugs for unapproved uses can put patients at risk by circumventing the FDA’s judgment over which products are safe and effective. For that reason, “off-label” promotion is against the law….
But when it came to prosecuting Pfizer for its fraudulent marketing, the pharmaceutical giant had a trump card: Just as the giant banks on Wall Street were deemed too big to fail, Pfizer was considered too big to nail.
Why? Because any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence…
So Pfizer and the feds cut a deal. Instead of charging Pfizer with a crime, prosecutors would charge a Pfizer subsidiary, Pharmacia & Upjohn Co. Inc.
The CNN Special Investigation found that the subsidiary is nothing more than a shell company whose only function is to plead guilty.
I don’t know how we’re supposed to think pharmaceutical companies are held to any measure of legal accountability when the FDA, whose function is to protect not just public interest but patient safety, puts the viability of its friends in industry first. On the basis of the “too big to nail” argument, it seems unlikely that our beloved drug makers will ever actually be treated as criminals no matter how criminal their actions. They’ll just pay their dues to the club in the form of relatively small cash settlements and carry on with business as usual.
Oregon Governor Vetoes Prescription Privileges for Psychologists: I recently posted about psychologists’ attempt to gain prescription privileges. Recently, Oregon Governor Ted Kulongoski vetoed the proposal in his state on the grounds that the shorter special session did not allow the time needed to thoroughly look into what was being voted upon. Given the impact such a change would inevitably have, it’s refreshing to see a politician take the slow and deliberate approach no matter how it ultimately ends up. Taking a decidedly different path than many states and our federal government, he decided against major changes decided in a short time with vague wording and too many loose ends. From Psych Central:
“I have a serious concern as to whether the special session in February provided opportunity for citizens and interested stakeholders to be adequately involved in the development of those proposed major policy changes,” Gov. Kulongoski of Oregon wrote in his veto letters.
Medical groups and even some psychologists — including Dr. John Grohol of Psych Central — opposed the bill. Gov. Kulongoski said such a change “requires more safeguards, further study and greater public input.”
And from the Oregon Politico:
Rem Nivens, spokesman for Governor Kulongoski, clarified that the Governor is supportive of the legislation which passed in February proposing a short, month long session in between regular sessions.
He added, however, that major policy changes, like the ones vetoed on Thursday, should wait to be brought up during a longer regular session. This will allow for the proper input from citizens and key players in the policy.
“The public give-and-take is critical to crafting and amending legislation by allowing all interested parties to be involved in the development of public policy,” Kulongoski stated. “I believe we must always be open and transparent when we are proposing changes to long established Oregon policy, especially in a short legislative session.”
It’s been an interesting couple of weeks for fans and admirers of indie music icon, Daniel Johnston. He recently commented on the documentary of his life and music, The Devil and Daniel Johnston. While I had already developed an interest in Daniel’s work and his story — which are inseparable — aside from the documentary, I had little to go on and it certainly gives you a strongly focused view of his life. Unfortunately, it may have been narrowly focused as well. The film has been criticized as being unbalanced in its portrayal of him as an always tormented, sometimes institutionalized semi-genius scratching out recordings in garages and basements while battling some pretty strong demons, namely bipolar disorder for which he was institutionalized. That’s not to say all of those things aren’t true, just that they’re not all of the truth.
If The Devil and Daniel Johnston is your only glimpse at his story, you’re likely to take away only one view of him. In hindsight it becomes a little clearer that in the film he was defined by several lapses in mental health while less interesting little details such as long stretches of productive wellness were downplayed like long straight interstate roads to more interesting breakdowns. To be fair, things like the incoherent rambling, sometimes violent outbursts and the plane crashed he caused could distract most people from music. It was a great film in many ways with a lot of tenderness and a good glimpse of his vision but you have to bring your own sense of balance to it. Be careful though, it might break your heart.
From BBC 6 Music:
“It wasn’t really fair because it really talked about the worst experiences of my life,” Johnston said. “I wish they had included more music instead of making it one of those Stranger Than Fiction shows.”
So, onto the music. Since one of his most characterizing breakdowns, he’s been hard at work — writing and releasing albums like he’s sending out pages from a journal — including one of my favorites, Fear Yourself. All of his albums are packed full of strange but endearing lyrics in that lo-fi recording so many people have come to know and love (or hate). One thing is certain — after all these years, regardless of the state of his mental health at any point, his songs are extremely exposing and honest which is refreshing among a sea of John Mayers pretending to feel something because it sells records housewives and teenaged girls.
His website refers to him as a”pilgrim of indie music with 30+ albums, hundreds of songs, and dozens of fans.” In fairness, that was written before the success of the documentary propelled him into the center stage spotlight. He’s now got countless fans, and devoted ones at that. All that notoriety and demand has led to well attended and often sold-out shows around the world and dramatically increased prices on his original artwork. This has finally allowed him to live off of his creations — products of the very mindset that have made things so difficult for him and often the people around him.
“It’s really cool that I’m making a living after all these years. I’m doing a lot better than I’ve ever done…I was starving to death working for McDonalds when I first got on MTV.”
He’s been working with a fervor but not just for its own sake or simply to meet an increased demand. Pouring his energy into creative outlets and always looking for his next opportunity appear to serve a distinct purpose in Daniel’s life. Given the limited options the world allows for someone with his extreme and changing states of mind, he may be left with little choice.
“I’d like to direct my own movies. I’m working on a film of my own and I want to direct it all myself,” he said. “[I’m planning] a variety show, with songs, videos and comedy skits all together.”
“I’ll do anything to stay out of hospitals, I spent five years in mental hospitals. All I can do is try again.”
For his latest project, Johnston released an album last week entitled Beam Me Up, consisting of three previously unreleased solo tracks and rerecorded versions of familiar Johnston originals (including Syrup of Tears, Devil Town and Walking the Cow) all backed by the eleven piece Dutch orchestra Beam. The fact that he’s released an album in march, having just released one in october speaks to his constant writing and recording. For him, it’s like breathing. I’ve heard a few short samples but have yet to get the album. So far it sounds like fans will love it and most of the rest of the world will wonder what the hell is going on and why anyone would buy it, which is something I’ve always liked about his music. It’s certainly not aimed at appealing to the broader tastes.
As if that wasn’t enough, filmmaker David Miller is working on a movie, an “epic superhero story,” about Daniel johnston — and the role of our hero may be played by Philip Seymour Hoffman, one of the few current actors worthy of the praise he gets with his wide ranging roles as an indie/offbeat actor. From The Guardian:
“It doesn’t really cover any of the same stuff as The Devil and Daniel Johnston documentary,” …. The director, who is in the midst of pre-production, finishing the screenplay and approaching possible actors, added: “There’s so many people reaching out that are huge Daniel Johnston fans. Philip Seymour Hoffman and John C Reilly for example. Johnny Depp’s a big Daniel Johnston fan, though we’d like him to play the older brother.”
I’m curious to see what it does cover. Yes, his life is full of stories worth telling but they are not all about missteps and failures and they’re not all about his mental health, whatever that means. Maybe this one will tell his story with a little more of the fairness he might hope for. If nothing else, it will be interesting to see Daniel Johnston portrayed in a hero’s light. As anyone familiar with his life and work knows, Daniel Johnston loves a hero.
Somehow the push for psychologists to gain prescription privileges has thus far flown under my radar. As soon as I became aware of it, a host of fairly obvious thoughts ran through my head. As any return readers might have guessed, not in favor of such a move. Now that we’ve broadened the range of thought and emotion caught up in the net that is psychiatry’s drug craze, we’re moving toward increasing the number of people casting such nets. In a culture where powerful and often deadly (but highly salable) drugs are the accepted answer to each of life’s concerns, the last thing we need is more prescribers. Needless to say, I’m not alone in these concerns and a recent article on Psych Central’s World of Psychology essentially echoes my thoughts on the matter.
If psychology wants to remain a science based upon the understanding of human behavior — both normal and abnormal — and helping those with the “abnormal” components, it would do well to avoid going down the road of prescription privileges. But perhaps it’s already too late…
It never ceases to amaze me that people can speak to a psychiatrist, present them plainly with the source of their emotional troubles, walk their doctor through their problem from onset to complete breakdown and be told they have a biological illness and given a prescription. Psychology as a profession is still in a position to offer real care for very real problems that result from life’s many stumbling blocks. The question is, is that enough?
The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy…
By switching to a heavily prescription-based practice, a psychologist will be able to nearly double their salary. Can you imagine any other field where you can double your salary with an additional 2 years’ worth of training? Are proponents actually suggesting that money has little or no significant impact in helping a person make career decisions? (We only have a few decades’ worth of research to demonstrate how money does indeed influence our decision-making process.)
Back when prominent psychiatrist Loren Mosher resigned from the American Psychiatric Association (APA), it was for just this reason. He saw his field’s practitioners getting all too cozy with drug makers — and then from cozy to dependent. It began with the blending of psychiatry and psychopharmacology in the early seventies and continued into what we see now — a field whose approach is virtually devoid of any connection between life and trauma, favoring instead to label everything a chemical imbalance with a chemical cure. It has become the goal of many psychiatrists not to pinpoint and address peoples’ actual sources of distress but, as a sales force for psychotropic drugs, to capitalize on their patients’ struggles with an endless but ever-changing and supposedly improving parade of pharmaceuticals. From his resignation letter:
After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for this action is my belief that I am actually resigning from the American Psychopharmacological Association. Luckily, the organization’s true identity requires no change in the acronym…These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts — rather we are there to realign our patients’ neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter — whatever its configuration.
When you look back to the late sixties and early seventies, when psychiatrists were seeing the vast majority of psychotropic prescriptions filled by general practitioners in a trend of declining credence in psychiatry, todays push seems all too familiar. That’s when psychiatrists started to flesh out the chemical imbalance theory as an exclusive (at the time) answer and a justification of their field, positioning themselves as the sole experts on the topic of biological cause to emotional struggles. It was never backed by objective scientific discovery or even verifiably observed in study but it sold well and justified the existence of psychiatry as an institution and a higher authority on the matter than GPs. The APA and its congregants could hold up the theory disguised as fact and point out that it was they and not GPs who came up with this exclusive supposed answer.
Is that where we are with psychology? In a time where we — as patients and consumers –are conditioned to think our emotional troubles and extreme states of mind are rooted not in our environment but in our chemistry, psychologists offer little in the way of addressing the chemical cause we’ve been sold. They are sitting back watching psychiatrists sell theories and pills in a monopoly while they are increasingly regarded as new age hucksters selling psychobabble. If they are going to remain socially relevant and commercially viable, they need to market themselves as better stewards of the same keys. It would appear, by the early actions of proponents of prescription privileges, that they would do this by taking on the legitimacy offered by psychopharmacology and the balance and apparent of purity of intentions offered by addressing factors like stress,abuse and emotional damage. You can already see them holding themselves up as not having gone down the road of greed and corporate influence but if they’ve taken the high road, it’s largely because the low road has been closed off to them. Sure, there is a great number of psychologists who truly believe in and act on the ability to relate emotional discharge to environmental input but if their era sunsets, the new blood will be trained in the new paradigm and it will be a lucrative one. I’m sure we can scarcely imagine what that will do to the notion of choice in mental health care.