I would gladly lend my illness, for one, to Speaker of the US House Dennis Hastert for a day. Despite overwhelming support for mental health parity in both houses of Congress and the endorsement of the President, he is refusing to bring the matter to a floor vote. His counterpart in the Senate, Majority Leader Bill Frist, is also dragging his feet. As for the insurance companies and their 222 lobbyists which in 2003, according to Public Citizen, spent $32.3 million defeating that measure and helping kill Medicare, they don’t need my illness - a special circle of hell is waiting where the fairways are all sand traps, the cell phones don’t work, the wine is from British Columbia, and the home team is any pre-2004 Boston Red Sox team.

Then there is the pharmaceutical industry, which according to the Center for Responsive Politics forked over nearly $27 million on campaign contributions and soft money for the 2000 election. That same year, according to Public Citizen, they spent $87.2 million on lobbying, and in 2003 $108.6 million, with 824 lobbyists, about 1.5 for each member of Congress. The pay-off well justifies their investment - the Medicare prescription benefit signed into law in 2003 will cost taxpayers $200 billion over ten years. The money will be funneled through private insurance companies (which spend 30 cents per dollar in administrative costs) instead of Medicare (which spends only about three or four cents per dollar).

There are no strings attached to the payout - the measure specifically prohibits the government from using its massive buying power to bargain for lower drug prices and rules out the re-importation of cheaper drugs from Canada. Meanwhile, the obscenely high cost of many psychiatric meds is virtually bankrupting state mental health programs, and the drug companies are working very hard to keep it that way.

Nearly all drug industry contributions have gone to Republicans, often targeted to support candidates in key swing districts, as well as the person at the top of the ticket in 2000. You’ve been warned - this is a Philippic. The economic recession that followed served up our population as its first victims, with mental health programs brutally slashed at every level - federal, state, and local. Revolving door treatment, drive-by consultations, and jails instead of hospital beds are now standard. Meanwhile "let no child be left behind" is a cruel joke to any parent struggling to afford treatment for a severely mentally ill son or daughter.

Over at the judicial branch, in July 2004 the US Supreme Court ruled that patients could not sue HMOs in state court for failing to pay for needed treatment. Instead, we must go to federal court, where the remedies are far more restricted. The Supreme Court has not been kind of late to patients and people with disabilities. Two of their decisions dealing with the Americans with Disabilities Act severely limit our right to bring suit, and they have the potential to inflict far more damage. Consider, for a moment, a court with two Antonin Scalias or two Clarence Thomas’ or two William Rehnquists. The prospect is as frightening to me as Omarosa from "The Apprentice" showing up every week at my support group and probably a lot more inevitable.

Make no mistake, I’m willing to be very generous in dispensing my illness. Let them all walk around with my brain for one day, I keep thinking, and see if they can survive. Maybe I’m giving them way too much credit, but perhaps the experience might do for them what Marley and his fellow ghosts did for Scrooge. Then I realize that thinking like this will get me nowhere. So I’m not going to get mad, I have decided, I’m going to get even - come November I’m going to vote.

Let us not underestimate our personal power. One day we’ll be a force to be reckoned with, but only after we have developed some good civic hygiene. If you haven’t registered, please do so without delay. Vote to cancel out my vote, if you have to, but please vote. Win or lose, simply putting up a fight is life-affirming. Thank you for indulging me. I’m feeling better, already.

[Nov 3 update: Sad to say, I failed in my attempt to fire the President, but I can draw some comfort in having tried.]

Philippic PM

As I was working on my Philippic, Public Citizen considerately came out with a report entitled, The Medicaid Drug War, with up-to-date lobbying data. The figures they provided are based on reports that companies and interest groups must file to Congress. They include only federal activities directed at Congress and the executive branch. Unaccounted for are public relations, media advertising, direct mail, state lobbying, research, and other undisclosed activities. Says the report: "Since Public Citizen began tracking the drug lobby in 1997, the drug industry has spent nearly $600 million on federal lobbying in Washington."

Philippic Extended Release

The following, drawn from a June 19, 2004 article in the British Medical Journal and the report of a whistle-blower, is admittedly one-sided, but it paints a revealing picture of the drug companies in action:

In June 2004, Allen Jones, an employee of the Pennsylvania Office of the Inspector General, was sacked for speaking to the media after he discovered that drug companies were allegedly illegally paying key state officials from of a slush fund to encourage them to introduce a medical algorithm that favors brand name drugs over cheaper generics.

The algorithm grew out of the Texas Medication Algorithm Project (TMAP) , favorably reviewed in elsewhere on my website (see article). The project was underwritten by the Robert Wood Johnson Foundation and the drug companies, and implemented in Texas in 1999. Three different algorithms deal with the meds treatment of depression, bipolar disorder, and schizophrenia. The previous year, pharmaceutical manufacturers contributed $152,000 to candidates for Texas state office, up from zero in 1994.

The TMAP schizophrenia algorithm lists first generation antipsychotics such as Haldol as a third treatment option, after two different newer generation atypical antipsychotics have failed. TMAP critics argue there is little difference in efficacy between Haldol (available as a generic) and the far more expensive brand name atypicals. The APA’s Practice Guideline for the Treatment of Patients with Schizophrenia published this year, however, makes a strong case for at least a marginal advantage of the efficacy of the atypicals over the first generation antipsychotics. As for safety, the APA notes: "More than 60 percent of patients who receive acute treatment with first generation antipsychotic medications develop clinically significant extrapyramidal side effects in one form or another," while the atypicals run far less risk of EPS. The APA, however, is far more comprehensive than TMAP in documenting an array of side effects unique to each atypical (such as extreme weight gain in Zyprexa), and recognizes situations where a first generation antipsychotic may be a first option.

Meanwhile, the President’s New Freedom Commission on Mental Health, chaired by Michael Hogan PhD who helped implement TMAP in Ohio as that state’s Director of the Department of Mental Health, has recommended the introduction of TMAP (which it touts as "evidence-based practice") into all states. A TMAP-conducted study of 350 patients with major depression found those who were treated according to the depression algorithm fared significantly better over 12 months than the treatment as usual patients.

The stakes are extraordinarily high: The BMJ cites a 2003 NY Times article that reported that 70 percent of Zyprexa sales are paid for by government agencies. RXUSA lists the unit cost of 15 mg Zyprexa at $13.99 vs $1.05 for 10 mg of Haldol.