Friday, June 27, 2008

Book talk in Waltham July 1

For those of you interested in hearing more about my book Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial, I will be giving a talk at Back Pages bookstore in Waltham on Tuesday, July 1 at 7 p.m.

This week, The New England Journal of Medicine gave the book a big thumb's up. (To read full review, go to Reviews). The reviewer, Dr. Richard Friedman, of Weill Cornell Medical College, wrote that Side Effects "used the case of Paxil to expose the unsavory and self-serving relationships among members of the pharmaceutical industry, psychiatrists, and members of the FDA" and that the book "has the brio of a crime thriller.” He concluded that this "riveting and well-researched account of these disturbing ties should be widely read by members of the medical profession, many of whom continue to believe, despite all evidence to the contrary, that they are immune to the influence of drug companies." Amen.

Monday, June 23, 2008

Pharmaceutical Giant under probe by Justice Department

GlaxoSmithKline is being investigated by the U.S. Department of Justice for its research and marketing of Paxil in both adults and children, according to the Wall Street Journal. US investigators are particularly interested in what Glaxo knew about the suicidal risks of Paxil when it sought approval for the drug with the FDA and when it promoted the drug for off-label use in children and adolescents.

The federal investigators were particularly interested in the Paxil clinical trial known as study 329, which is the focus of my book, Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial. As Side Effects reveals, the authors of study 329 concluded that Paxil was safe and effective in adolescents, even though the actual data in the study showed the opposite. This particular study has come under fire from other independent medical researchers as well; see my previous blog Drug company under fire for Paxil research. Sen. Charles Grassley (R-Iowa) has also demanded an investigation of Paxil’s approval by the FDA.

Even as this controversy gains momentum, the drug industry is not standing idly by. Allan Lundy, a psychologist who receives research funding from the industry and has done antidepressant trials for several drug companies, wrote a largely negative review of my book – no surprise there. What is surprising is that a once respected newspaper, The Philadelphia Inquirer, published the review without questioning Lundy’s partiality. I guess this is what happens when economically squeezed newspapers cut their own book review staff and don’t vet freelancers' credentials.

Sunday, June 15, 2008

Drug company under fire for Paxil research

A perfect storm seems to be gathering over GlaxoSmithKline and research it funded to determine whether its antidepressant drug Paxil was effective in treating depression.

In March of this year, Australian researchers published an article in the International Journal of Risk and Safety in Medicine on one particular study of Paxil, known as study 329, that purported to show that the drug was more effective than a sugar pill or placebo in treating depression in adolescents. After re-examining raw data from the study, obtained from GlaxoSmithKline under subpoena, the IJRSM researchers instead concluded the data showed that Paxil was no more effective than placebo on all eight of the study’s pre-specified clinical outcome measures. They also found that after the study blind was broken, the researchers added a number of new outcome measures in order to show a statistically significant difference between Paxil and placebo. In other words, as the IJRSM paper concludes, the authors of study 329 manipulated the data. Shortly after this finding was published, Dr. David Egilman, a clinical associate professor at Brown University, filed an ethics complaint against Dr. Martin Keller, the principal investigator of study 329 and chief of psychiatry at Brown. Egilman says Brown’s provost wrote him a letter in May saying that the university reviewed the allegations against Keller, but declined to say what, if any, action it was taking against its long-time psychiatry head.

Likewise, in my book Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial, due out Tuesday, I also reveal new information showing that Keller and his co-authors misrepresented data in study 329. In essence, Keller et al miscoded several teenagers as being noncompliant when in fact they were in fact suicidal, thus further skewing the results of this controversial study. Furthermore, as I show in my book, at the very same time Keller was touting study 329 as a positive finding for Paxil (even though the actual data showed the opposite), GlaxoSmithKline was paying him thousands of dollars in personal consulting income.

Finally, just last week, Senator Chuck Grassley (D-Iowa) released a report by Joseph Glenmullen, a Harvard psychiatry instructor, alleging that Glaxo researchers misrepresented data in an earlier study comparing the effectiveness of Paxil and placebo in treating depression in adults. In this 1989 clinical trial, which was used to gain FDA approval for Paxil, Glaxo counted as suicides in the placebo arm of the study, deaths that had actually occurred during the wash-out period of the study. The suicides, thus, occurred before the official start of the study and should not have been counted as placebo suicides, Glenmullen's report contends. Glenmullen prepared his analysis for a law firm who is suing GlaxoSmithKline, and he concludes that the wash-out suicides were included in the study to make Paxil look safer and more effective than it really was, according to The Wall Street Journal. The Journal quoted Glenmullen as saying, “Glaxo was aware of this risk and hid it.”

Taken together, all of this new evidence indicates that the real risk of suicidality from Paxil was far greater than its risk for patients on placebo. As Glenmullen notes in the Journal article, if the FDA had had the correct information back in 1991, when the agency first examined suicidal risks of the SSRI antidepressants, it might have issued warnings about these drugs then. Instead, the FDA didn’t require black box warnings about the suicidal effects of these drugs until 2004. And that raises the haunting question: How many young people’s lives were lost to suicide in the intervening 13 years?

Monday, June 9, 2008

Financial Conflicts between Doctors and Drug Companies Taint Research System

Senator Charles Grassley (R-Iowa) recently released records showing that a prominent psychiatrist whose work led to an exponential increase in the diagnosis of childhood bipolar disorder earned at least $1.6 million from the makers of drugs used to treat this very disorder. As The New York Times reported yesterday, Dr. Joseph Biederman, of Massachusetts General Hospital and Harvard Medical School, may have violated federal research rules by failing to disclose the extent of his payments from drug companies over the years.

Sadly, such blatant conflicts of interest are all too common. In a 1999 article in The Boston Globe, I wrote about another prominent psychiatrist, Dr. Martin Keller, chief of psychiatry at Brown University, who had earned more than a million dollars in 1997 and 1998 from the pharmaceutical industry, much of it from companies whose drugs he was studying and touting at conferences and in medical journals. In 1998, for instance, the same year that Keller published positive findings about Zoloft in the treatment of depression, Keller earned $218,000 in personal payments alone from Pfizer, the maker of Zoloft; he also received $77,400 from Bristol Myers Squibb, the maker of Serzone, the same year he was lead author on a positive study about Serzone, an antidepressant that has since been taken off the market because it causes liver failure. Keller, oddly enough, did not report any income from SmithKline Beecham on his 1998 return, a copy of which was obtained by The Globe.

It was not until I began researching my book Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial that I discovered that Keller had indeed earned personal income from SmithKline Beecham (now GlaxoSmithKline), in 1998 as well as subsequent years. He admitted as much under oath in a deposition in a lawsuit against GlaxoSmithKline, the maker of the antidepressant Paxil, in September 2006. Why is this important? To begin with, Keller was the principal investigator of a major multi-center study of Paxil, which purported to conclude that Paxil was more effective than placebo in treating depression in adolescents. Just as with Biederman, Keller’s acceptance of money from the maker of a drug he was studying constitutes a blatant conflict of interest. And just like Biederman, Keller failed to disclose these conflicts to the federal agencies that were rewarding him millions of dollars in research grants. Equally important, if as Keller himself acknowledged under oath, he received payments from SmithKline in 1998, why didn’t that income appear on his 1998 tax return?

Tuesday, June 3, 2008

Time to Ban Drug Gifts and Rebates to Doctors?

The Boston Globe yesterday published my op-ed piece here about the extent to which drug companies run misleading ads and use rebates to essentially bribe doctors to prescribe their drugs. I received some interesting feedback, including an email from a lawyer who noted that the legal profession operates under ethical standards that forbid blatant conflicts of interest. He wondered why the ethical guidelines for doctors are more lax, which prompted me to investigate. And he's right: guidelines promulgated by the American Medical Association do not prohibit doctors and dialysis centers from taking substantial rebates on drug supplies they purchase from companies, or from accepting gifts, including meals and free lunches, from drug makers as long as the "gifts are related to the physician's work and are of minimal value (the AMA defines minimal value as gifts of $100 of less, which doesn't seem so minimal to me).

In addition, while doctors in this country are not permitted to own pharmacies, they are allowed to accept rebates and to own or have a financial interest in imaging labs or centers to which they can then refer patients. In an interview today, Dr. Daniel Carlat, a psychiatrist and author of The Carlat Psychiatry Blog, said he considers that "a conflict of interest since it gives doctors a financial incentive to over refer patients to these labs." The same principle is at work when doctors accept generous rebates based on the amount of drugs they prescribe.

As I note in my new book Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial, research has shown that such largesse from drug makers can and does influence doctors' prescribing patterns. For that reason, the Massachusetts State Senate recently passed a bill banning any gifts from the pharmaceutical industry to doctors in the state. The bill is currently being considered by the state House of Representatives. If it becomes law, Massachsuetts would join Minnesota and Vermont in either banning gifts worth more than $50 or requiring public disclosure of such gifts, according to The Carlat Psychiatry Blog here .

Seems to me the AMA could do a lot more to discourage doctors from accepting gifts and rebates from the pharmaceutical industry. And so could our state and federal legislators.