This post will be the second in an occasional series that discuss the more subtle and insidious devises used by Pharma-connected "experts" to mislead - or should I say con - practitioners. These "experts" are called opinion leaders by Pharma and are a major part of their psyche ops. Their marketing departments have been scrupulously studying physician behavior - especially physician weaknesses - for decades. I will also discuss in future posts some of the ways they have done and are doing that.
An excellent discussion of the more obvious and better-known pharma marketing techniques can be found at http://www.abc.net.au/rn/backgroundbriefing/stories/2011/3337618.htm. This program is from the Australian media, but the situation is much the same in the US. I will not be focusing on those techniques much in these posts.
Pharma marketing targets all physicians, not just psychiatrists, although psychiatrists have been a leading target. Of course, I am more familiar with the marketing of psychiatric drugs, so my main focus will be those.
Of course, it is ultimately the fault of the practitioner for not taking the time to challenge misleading ideas and to check them out with unbiased and readily available sources of scientific information such as the Medical Letter. But that is, in a way, the point. Pharma knows quite well that many practitioners will not have either the time or inclination to do this. The average physician works about 60 hours per week.
Not only that, but many are also suckers who can be easily deceived.
BTW, did you know that 80% of antidepressant medications are prescribed by non-psychiatrists?
In this post I will discuss how Pharma-inspired or paid-off writers in psychiatric newspapers, throw-away journals, and journal supplements denigrate highly-effective drugs (antidepressants and benzodiazepines) that just happen to have gone generic, in hopes that doctors will prescribe more expensive, potentially more toxic, and less effective brand-named drugs (particularly atypical antipsychotics).
(And yes, antidepressants and benzo's do not work for everyone, can cause severe side effects in some people, can be habit forming, may cause unpleasant withdrawal reactions, blah blah blah. [All of these problems can be dealt with by a competent physician who follows his or her patients closely]. And a majority of patients need psychotherapy instead of or in addition to medications. No sh*t! So please don't keep writing to me to point out the obvious).
I am going to use as illustrations two articles that appeared in a newspaper called the Psychiatric Times. I do this because two very recent articles that clearly illustrate my points appeared there, not because I want to pick on that particular publication. In fact, Psychiatric Times tends to be rather fair in general and is one of the most pharma-critical of the publications I am talking about.
By way of definition: Throw-away journals are official-looking medical "journals" that are mailed free of charge to all doctors who might prescribe certain drugs pushed by big Pharma. Psychiatric Annals (Anals?) and Current Psychiatry are two examples from psychiatry.
They are heavy on full-page and sometimes multi-page Pharma advertisements, and Pharma probably pays to produce and mail them. The articles they contain are not peer reviewed (sent out to about three independent experts for review of the adequacy of their science prior to a decision by the journal editors about whether or not they should be published).
Journal Supplements are mini-journals mailed along with more legitimate, peer-reviewed journals (and usually having the same cover design) that consist of multiple articles which claim to review a particular topic in the field. Most doctors are unaware that the articles in a journal supplement are not peer reviewed like the articles in their accompanying primary journal, and that the supplements are usually sponsored by one pharmaceutical company.
First, an article about anti-depressants. I submit as evidence for my contention in the Plausible Deniability post (that the article by Sachs and others claiming that antidepressants are ineffective in bipolar depression is being used in the field to push other medications) the CME article "Understanding and Treating Bipolar Depression" by Caleb Adler, M.D. It appeared in the July, 2011 issue of Psychiatric Times. As mentioned, there are a lot more articles like this one in various publications.
I pointed out in the previous post that drug companies did not need the folks who authored the Sachs article to recommend anti-psychotics for bipolar depression. They have a lot of other people to do that particular job for them. ("Opinion leaders" is the term Pharma uses for such people), like the authors of articles like these.
The Times article lists a variety of treatment options for bipolar depression including various atypicals and mood stabilizers, and even mentions neurontin and lamictal - both of which have both been shown to be particularly ineffective - before mentioning, at the very last, standard antidepressants.
After focusing on the red herring of antidepressants causing switching into mania - which even the author grudgingly admits can be easily prevented with drugs like lithium that true bipolar patients should be taking anyway - it speaks of the use of antidepressants as "fairly controversial," even though they have been used successfully for over fifty years.
Then the reference to the Sachs et. al. article come in: "Nonetheless, the large STEP-BD analysis did not observe improvement in patients receiving standard antidepressants. Other meta-analyses that have purported to observe an effect may be methodologically flawed."
I do not see any mention that this part of the STEP-BD study was a study ONLY of treatment-resistant subjects, or that it used only two antidepressants for that matter.
And what is the unspoken implication of that last statement about the meta-analyses, even though it may be literally true for any given study? (The reference cited for this statement, by the way, was just another article in Psychiatric Times!) It is this: that any study which purports to show that antidepressants work is probably methodologically flawed, that's what. There are no similar caveats attached to any of the other drugs mentioned in the review.
A lot of plausible deniability built into the wording though. Brilliant marketing.
The second article concerns benzodiazepines and is titled, "Anxiety Disorders: the Anxious Bipolar Patient" by MD's Khavital Lohano and Rif S. El-Mallakh in the September 2011 issue of Psychiatric Times. The article correctly points out that many bipolar patients also have severe co-morbid anxiety disorders like panic disorder, which often require additional meds (an instance in which polypharmacy may sometimes be legitimate and necessary).
In one study, 21% of bipolar patients had panic disorder - a 26 fold higher incidence than in the general population.
Interestingly, the panic attacks in manic-depressive patients do not occur when a patient is in the manic state. They occur when the patient is in the normal (euthymic) mood state or, more frequently, in the depressed phase of the illness.
Certain benzodiazepines are, in my experience, far and away the most effective medications for panic disorder, whether it is comorbid with something else or not. The second most effective drugs are antidepressants.
Of course, just as with the last article, in discussing treatment options this one goes out of its way to stress that antidepressants can induce mania, without mentioning that anti-manic drugs prevent this from ever happening.
At least antidepressants were the first class of drugs mentioned. The second? Antipsychotics, of course. They are actually stated to be the second line drugs for this indication! Without FDA approval, I might add. And the FDA happens to be absolutely right in not approving them for this indication.
Listed third was anticonvulsants like depakote. Interestingly, the article admits, "There are no randomized controlled trials that examine the use of anticonvulsants for the anxiety component in bipolar patients." But, naturally, it goes on to state, "However, anticonvulsants appear to have a small effect in reducing anxiety." Side effects were not even mentioned about either antipsychotics or anticonvulsants anywhere in this article.
Next, under "alternative agents," the article discusses the anticonvulsant gabapentin, which in my experience has very mild tranquilizer-like properties but is not FDA-approved for anxiety.
LAST, the article finally and very briefly mentions benzodiazepines. Get this: and I quote: "Benzodiazepines are clearly effective in many types of anxiety disorders. However, their use is problematic, and these agents must be prescribed cautiously."
So what, the fact that antipsychotics can cause diabetes is not problematic and did not need to be mentioned in the article like the problems with benzo's were? Or the fact that depakote can cause polycystic ovaries in females? No caution needed in prescribing those agents, I guess.
Even in mainstream publications and in the APA Treatment Guidelines, whenever benzodiazepines are mentioned, one almost always also sees a phrase added that is something similar to, "But of course they can be addictive." On the other hand, when antipsychotics are mentioned, one almost never sees a phrase like, "But of course they can cause diabetes, massive weight gain, higher cholesterol, and an irreversible neurological disorder called tardive dyskinesia."
Agree completely, which is why I dispose of these annoying so-called journals with as much celerity as the credit card solicitations. My question is: Where are medical schools falling short in our training and preparation of future physicians who apparently fall for such nonsense, before unleashing them on the public. PT Barnum said "There's a sucker born every minute", but he was a carnival promoter for Pete's sake! Are physicians really that naive and incapable of critical thinking after so much education, particularly in the sciences?? Or, in the field of psychiatry especially, do they become corrupted at some point and develop a defense mechanism, primarily denial, that requires them to maintain their psuedoscientific orientation, so as not to self-confront their dearth of clinical skills? Perhaps some are simply antisocial and consciously exploit the masses for their own secondary gain. Either explanation suggests an ominous future for our profession, and maybe that's a good thing.
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