The Good, the Bad, and the Ugly
Steven S. Sharfstein, M.D.
Psychiatric News August 19, 2005
Volume 40 Number 16© 2005
APA's annual meeting is one of the largest medical meetings in the United States and the largest psychiatric meeting in the world. There is something for everyone at our wonderful meeting, but many have commented to me on the extraordinary presence of the pharmaceutical industry throughout the scientific programs and on the exhibit floor.
The U.S. pharmaceutical industry is one of the most profitable industries in the history of the world, averaging a return of 17 percent on revenue over the last quarter century. Drug costs have been the most rapidly rising element in health care spending in recent years. Antidepressant medications rank third in pharmaceutical sales worldwide, with $13.4 billion in sales last year alone. This represents 4.2 percent of all pharmaceutical sales globally. Antipsychotic medications generated $6.5 billion in revenue.
When the profit motive and human good are aligned, it is a "win-win" situation. Pharmaceutical companies have developed and brought to market medications that have transformed the lives of millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilizing, and antipsychotic medications has helped sensitize the public to the reality of mental illness and taught them that treatment works. In this way, Big Pharma has helped reduce stigma associated with psychiatric treatment and with psychiatrists. My comments that follow on the pharmaceutical industry and its relationship to psychiatry bear this in mind.
The interests of Big Pharma and psychiatry, however, are often not aligned. The practice of psychiatry and the pharmaceutical industry have different goals and abide by different ethics. Big Pharma is a business, governed by the motive of selling products and making money. The profession of psychiatry aims to provide the highest quality of psychiatric care to persons who suffer from psychiatric conditions. There is widespread concern of the over-medicalization of mental disorders and the overuse of medications. Financial incentives and managed care have contributed to the notion of a "quick fix" by taking a pill and reducing the emphasis on psychotherapy and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications.
In my last column, I shared with you my experience, and APA's, in responding to the antipsychiatry remarks that Tom Cruise made earlier this summer as he publicized his new movie in a succession of media interviews. One of the charges against psychiatry that was discussed in the resultant media coverage is that many patients are being prescribed the wrong drugs or drugs they don't need. These charges are true, but it is not psychiatry's fault—it is the fault of the broken health care system that the United States appears to be willing to endure. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the biopsychosocial model to become the bio-bio-bio model. In a time of economic constraint, a "pill and an appointment" has dominated treatment. We must work hard to end this situation and get involved in advocacy to reform our health care system from the bottom up.
Furthermore, continuing medical education opportunities sponsored by pharmaceutical companies are often biased toward one product or another, and they are more akin to marketing than CME. APA has strict guidelines for the industry-sponsored symposia presented at our annual meetings; sanctions are applied when our rules are broken. Our guidelines have been held up as a standard for medical meetings in other specialties throughout the country. But there are many grand rounds, evening dinners, and lectures where such standards do not prevail.
Direct marketing to consumers also leads to increased demand for medications and inflates expectations about the benefits of medications. As a profession, we need to be concerned about advertising and the impact it has on the over-medicalization of our field. Of course, what is marketed to consumers are the highest-cost, on-patent products, and the cost of medications is something rarely considered by prescribing clinicians. When doctors don't prescribe cheaper but equally effective drugs, it consumes money that could have been used to provide other psychiatric or medical services.
There are examples of the "ugly" practices that undermine the credibility of our profession. Drug company representatives will be the first to say that it is the doctors who request the fancy dinners, cruises, tickets to athletic events, and so on. But can we really be surprised that several states have passed laws to force disclosure of these gifts? So-called "preceptorships" are another example of the "ugly"; that is, drug companies who pay physicians to allow company reps to sit in on patient sessions allegedly to learn more about care for patients and then advise the doctor on appropriate prescribing.
Drug company representatives bearing gifts are frequent visitors to psychiatrists' offices and consulting rooms. We should have the wisdom and distance to call these gifts what they are—kickbacks and bribes. (For more thoughts on this topic, see Viewpoints on page 33.) If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised.
Here are several suggestions for remedies in our relationship with the industry.
We need to embrace a new professional ethic. The doctor-patient relationship should not be a market-driven phenomenon.
Preceptorships should be considered unethical.
Enticements, gifts, parties, and so on should be reined in because patients must believe that their doctor has their best interests in mind when a prescription is handed to them.
We must re-evaluate single-sponsored medical education events and phase them out in favor of more general support for CME along with a careful policing of these events for bias.
The amount and support received by individual clinicians and researchers from industry should be transparent and the information readily available.
When we attend lectures at annual meetings and other educational events, and read journals and textbooks, we should know very clearly about the industry support given to presenters and authors.
As psychiatrists, we should all be grateful for the modern pharmacopia and the promise of even more improvements in the future. At the same time, however, we must be very mindful that we cannot accept gratuities in the new medical marketplace.
Thoughts on Pharmaceutical Companies and Gifts to Physicians
Psychiatric News 2005 40: 33. [Full Text]