Friday, March 20, 2009

Is psychiatry more corrupt than other medical specialties?

At a talk I gave Wednesday at George Washington University, someone in the audience asked why there seemed to be an inordinate number of psychiatrists on the take to the drug industry. Was it something about the specialty of psychiatry itself or the individuals involved? I have often pondered the same, especially since this is not simply an anecdotal observation. In 2007, The New York Times examined the payments made to all doctors in Minnesota in the years since that state passed one of the first laws in the nation requiring the public disclosure of payments from the pharmaceutical industry. Based on that investigation, Times reporters concluded that as a specialty, psychiatry topped the list in lucrative drug company payments.

So what's going on? A couple of things, I think. First off, there's a reason why drugs like Paxil, Zoloft, Prozac and Lexapro are top sellers: it's easier to expand the criteria for who might benefit from these drugs. After all, almost everyone has experienced depressive or anxious symptoms at one time or the other, so if the makers of these drugs can reach psychiatrists and persuade them to prescribe pills for such universal symptoms, we're talking real profits here. And what better way to influence psychiatrists' prescribing behavior than to put their most prominent colleagues -- the key opinion leaders (KOLs) -- on your payroll?

Secondly, as someone who came to the talk astutely noted, psychiatrists have been squeezed by managed care into the role of pill prescribers. Unlike other medical specialties, doctors in psychiatry don't get adequately reimbursed for treating the whole patient -- by doing psychotherapy, for instance -- so all they can do these days is prescribe drugs. In a sense, psychiatrists are gatekeepers for the pharmaceutical industry, much like surgeons (who put in stents and other devices) are gatekeepers for the medical device industry.

Because of these trends, partnering with the drug industry has become a pervasive part of the psychiatric culture in recent years. It has become, for example, common practice for drug companies to bankroll symposia at the specialty's top medical conferences, at which psychiatrists on their payroll extoll the benefits of their products (without disclosing their conflicts of interest). As I reported in a previous blog, Nada Stotland, the current president of the American Psychiatric Association (APA), initially took umbrage when Sen. Charles Grassley questioned the organization's incestuous ties with the drug industry. In a memo to APA members, Stotland wrote: "Long traditions and established practices are not only being questioned, but also criticized across the board." As I said then, it almost sounded like Stotland's problem was with the criticism of these longstanding practices, not the practices themselves.

And that is why I was gratified to see in the Carlat Psychiatry blog, that the APA has officially decided to phase out all industry-funded symposia that take place at their annual meetings.

That's a good first step to reform. But there is still a long way to go, as evidenced by the news reported today in The New York Times that court documents appear to indicate that Dr. Joseph Biederman promised a drug company (Johnson & Johnson) positive results about its drug Risperdal from studies that had not been undertaken. Biederman, as has already been reported, not only earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 (the bulk of which he failed to report), but also received funding from J&J for a research center at Massachusetts General Hospital, which he headed.

Like Martin Keller, the psychiatrist I expose in my book, Biederman is one more example of how science can be skewed and public interest harmed when doctors are the beneficiaries of industry largesse. Psychiatry may be particularly vulnerable to such corporate blandishments, but I would argue that it's time for all medical specialties to take a good look at the way they do business and start healing.


Dan said...

While I did not read the entire article, I believe that there is such a saturation of psychotropic drugs out there, that all the big pharma companies seek this specialty to be speakers and key opinion leaders.

Also, they are a specific specialty. With a statin drug, for example, you can develop any specialty as you wish to be a speaker or KOL for your drug company promoting such a drug.

Same with a drug with hypertension. The psychotropics belong to this specialty.

About 20 percent of all drug dollars spent go to generics. Most go to the following:

Top 10 drugs by sales, as of 2007:

1. Lipitor (Most do not need this powerful statin to manage their dyslipidemia, and also considering there are generic statins that would likely be just as effective, and less expensive.)

2. Nexium (It's prilosec OTC in a different-colored pill, biochemically. Why pay so much more, and why is this prescribed?)

3. Advair

4. Plavix

5. Seroquel (No more efficacious than the older antipsychotics such as Haldol, yet likely more toxic to the user of this atypical class of meds.)

6. Singulair

7. Enbrel- One of the first biologics for autoimmune diseases- specifically those related to various forms of arthritis. This biologic makes over 3 billion dollars a year.

8. Prevacid

9. Epogen (another biologic identical to the number 10 one. They sell these biologics to dialysis clinics. For every 100 dollars of epogen sold to a dialysis clinic, it only costs the maker less than 15 dollars.

10. Aranesp- EPO drug as the one above. Each one of these biologics make over 3 billion dollars a year, and they are paid for by medicare part B.

David Dobbs said...


Nice post. I'd offer one other factor that might encourage pharma to focus efforts on psychiatry: the high potential for long-term use once a patient starts using a drug. Those who feel relief, whether via medicinal efficacy, placebo effect, success of concurrent sychotherapy, a helpful change in circumstance, or just the healthy adjustment that time's passage sometimes brings, are often understandably hesitant to risk relapse by dropping their meds. Sometimes their worst fears seem confirmed if they try to drop too quickly without slowly tapering the dosage -- and resume, mistaking withdrawal symptoms for relapse. It doesn't help that few docs know such tapering is necessary (though that's getting better.)

I suspect you're aware of this but felt your post was long enough - but thought I'd mention it as it seems a major incentive to focus marketing efforts on psychiatrists, along with the factors you note.


David Dobbs

Alison Bass said...


Good point -- thanks!


Andy Alt said...

I think it's a little easier, in some cases, for psychiatrists to "get away" with more. Generally speaking, they're dealing with a more vulnerable demographic, and one that is less likely to complain to higher authorities or file malpractice suits.

I suppose there are different factors at play, and I also agree with David's assessment.

Andy Alt said...

Some things that aired on Minnesota Public Radio

January 14, 2009
Drug companies ban trinkets, but will it make a difference?

May 10, 2007
Commentary: Doctors and drug companies too cozy

March 21, 2007
Spotlight begins to shine on link between drug companies and doctors

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