Steven Sobel, MD
Cell 2 Soul. 2005 Summer; 1(2):a11
As a psychiatrist working at a community mental health center, my role has focused on diagnostic evaluation and pharmacotherapy. Many factors beyond the obvious, such as changes in scientific data, can clearly have an impact on prescribing practices. I have long been aware of the tightrope that we psychopharmacologists must walk as we strive to take advantage of pharmaceutical advances while avoiding manipulation by pharmaceutical companies. I have been struck by the blurring of boundaries that occurs between scientific evidence and medication advertisements.
An unrecognized force is exerting increasing influence over modern psychiatry. Of course, Freudian concepts still permeate psychiatry, although in recent decades Freud has been overshadowed by the "biopsychiatrists". This leads to a productive and legitimate dialectic. But there is another powerful player on the field who does not necessarily play by the rules of the game, namely the pharmaceutical industry.
Pharmaceuticals have deep pockets and have seduced many of the leaders of the field of psychiatry (and most, if not all, other fields of medicine for that matter). Academic psychiatrists and researchers all too often receive some sort of payment or funding from these companies. Many of the top academics accept reimbursement for pharmaceutical company sponsored lectures. In these talks, invariably, the attendees receive the message that the drug produced by the sponsoring company just happens to be the best treatment for whatever condition is being discussed. These lectures compete successfully for audiences at the annual meeting of the American Psychiatric Association for example. These "Industry Symposia" encompass a significant proportion of the APA annual meeting curriculum. Furthermore many journals have "free" supplements, which are sponsored by a pharmaceutical company. The articles in the supplement may not be subject to peer review and of course, the reader of the supplement is led to the conclusion that the sponsor's medication is the medication of choice for whatever disorder is the topic of that supplement.
New medications approved by the FDA are launched into the market by huge marketing blitzes, including hordes of "drug reps" who pay visits to doctors' offices and ply them with gifts, dinners, and other perks. Although, some degree of regulation may have eliminated the more egregious examples of seductive gift giving (white water rafting trips, paid vacations to Europe in return for giving a lecture sponsored by the drug company), the efforts to seduce continue. Many practicing psychiatrists have insufficient time to review the original research articles regarding the new medications and may receive the bulk of their "education" about them from these drug reps who have been taught to deliver a spiel.
Drug company marketing also affects diagnostic trends within psychiatry. For example, with the advent of additional patented medications for bipolar disorder (such as Depakote, Lamictal, second generation antipsychotic medications), has come increasing emphasis on the hitherto tendency to "under diagnose" the disorder. In addition, a whole new "fuzzy" category has been introduced i.e. "bipolar spectrum disorder". This spectrum consists of very vague entities, which then tremendously expand the range of indications for the medications. Adolescents with behavioral problems or moodiness become included under the bipolar rubric. Increased diagnosis of attention deficit disorder in both children and adults followed the introduction of patented medications for its treatment such as Concerta and Strattera.
Much of the clinical research conducted regarding new treatments is funded by pharmaceutical companies. Although, these studies are generally scientifically valid, they nevertheless may involve subtle forms of bias. For example, some studies of newer antidepressants have chosen to compare the new antidepressant to an older one that is especially likely to cause adverse effects such as imipramine. Not surprisingly, the conclusion reached is that the new medication is better tolerated.
Interestingly, when the selective serotonin reuptake inhibitors or SSRIs (such as Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro) were first introduced their selectivity for effects on serotonin was touted as an advantage over the older antidepressants, which affected serotonin, norepinephrine and other receptors. Now, another generation of "dual action" antidepressants (which affect serotonin and norepinephrine) is being promoted as more effective than medications that affect only a single receptor. Second generation antipsychotic medications (e.g. Zyprexa, Risperdal, Seroquel) were advertised as a major advancement over the older antipsychotic medications because of a significantly reduced rate of tardive dyskinesia, an irreversible neurological adverse effect. They have largely replaced the older medications in clinical practice despite being extremely expensive in comparison. However, it has turned out that they have significantly greater risks of causing weight gain and adverse metabolic effects such as diabetes and lipid dysregulation. Another tactic of drug companies is to repeatedly claim a potential advantage so often that it eventually becomes assumed by most clinicians that this is an established fact. For example, it has been claimed that the second-generation antipsychotic medications may be more helpful with cognitive deficits and negative symptoms in schizophrenia. (Negative symptoms include symptoms such as lack of emotional expression, limited production of speech, lack of motivation, etc). There are theoretical reasons to believe this may be the case, but there is insufficient evidence to establish this as fact. However, when the claim that the new medications may be more effective is repeated ad infinitum the word "may" eventually gets dropped and it becomes part of clinical lore that they are more effective.
The opposite situation also arises. For example, for many years the tried and true benzodiazepines were not actively promoted by the pharmaceutical companies, which preferred to push their newer brand-name antidepressants for anxiety disorders. The marketing "information" pointed out that the antidepressants were not addicting and generally condemned the use of benzodiazepines. However, the benzodiazepines are in fact very effective and often used though most psychiatrists will only reluctantly prescribe them (and would admit to doing so only with embarrassment) partly no doubt because of the propaganda campaign against them. Ironically, it later came to light that many of the antidepressants induce severe withdrawal symptoms though they are not labeled as "addictive".
The pharmaceutical companies' pronouncements regarding "dramatic progress" made in the treatment of psychiatric disorders contribute to patients' expectations of a magic, immediate and passive cure. (In fact the effectiveness of most medications is fairly modest at best. Many studies actually find no difference between antidepressants and placebo or "sugar pills" for instance). This has led to decreased value placed on psychotherapy (of course managed care policies have also tended to promote medication "quick fixes" rather than allow more intensive talk therapies). This is no more justifiable than the promotion of snake oil and other nostrums of yesteryear. The "education" (read: manipulation and brainwashing) of physicians by drug companies is a dangerous force. The field needs to increase its vigilance regarding such trends and its efforts to counter these with fact not fiction.