Physicians as Unwitting Research Subjects

"We'd like to invite you to join your colleagues and thought leaders in the field for a discussion concerning a new treatment for major depression."

This sounds like something that a busy physician, trying to keep up with the latest developments in the field, might really benefit from.  I continue to get invitations that sound just like this one.  The group sponsoring such discussion groups is not usually identified clearly in the invitation, but if it is mentioned the name usually contains words like "medical education."  Of course, the sponsor does not formally offer the kind of Continuing Medical Education most physicians require for keeping their medical licenses.

When I was a young and somewhat naive psychiatrist back in the early 1980's, I responded to one of these invitations to learn about a new antidepressant called Desyrel (generic name: trazodone).  This medicine is used today primarily in low doses (25 -  150 mg.) as a non-addictive sleep medication because many people find it extremely sedating.  The anti-depressant dose, rarely prescribed because many people taking it have trouble staying awake, is 400 to 600 mg per day.  Consequently, many doctors don't think it is an effective antidepressant because they never prescribe anywhere near that much.

Desyrel came out in the years before the SSRI antidepressants like Prozac and Paxil were on the market, and many docs were looking for alternatives to tricyclics like Elavil or imipramine, and MAO inhibitors like Nardil, since those medications often cause a lot of side effects and are also fatal if taken in overdose.  The real sponsor of the discussion group - the pharmaceutical company making Desyrel - was well aware of this and was looking for the best ways to take advantage of this situation in order to increase the number of prescriptions being written for its new drug. 

And not just by having doctors learn about the drug.

In fact, the real and covert reason for sponsering such discussion groups in the first place is to study physician behavior.  Of course, I did not know that at the time.  The drug companies were putting doctors under the microscope to determine the best ways of marketing their products.  They still do this, and they are very good at it.

Looking back, I remember the "leader" of the discussion asking the panel, "If I told you that Desyrel works much faster than tricyclics, would that be something that would be important to you?"  Since anti-depressants, when they work for Major Depressive Disorder, do not begin to kick in for about two weeks, and do not provide their full benefits until five to six weeks have elapsed, this would indeed be a fine selling point.

"Of course," most of the members of the now quite excited discussion group replied.

Since then, almost every new antidepressant, up to and including the latest one called Viibyrd, has made the claim that it has an earlier onset of action than all the others. 

For the record, none of them actually does.

The pharmaceutical industry shows particular interest in discussion group members who seem reluctant to endorse their new product.  These folks become objects of more intense study.  The group leaders probe these persons to find out exactly what might convince them to prescribe the new pill.  How can they best appeal to them?  Feed their ego in some way?  Preach patient convenience?  Which side effects are they most concerned about? 

The answers to these questions are not only used to develop overall strategies for pharmaceutical sales reps to use with reluctant prescribers, but are also used to compile information on individual physicians in the area, so sales reps can prepare themselves with a plan that is highly tailored to each physician. The plan is then used on the unsuspecting practitioner to help increase the number of prescriptions for their drug that that doctor writes.

The success of the reps is then monitored by the company by studying the prescribing practices of the given physician.  This information is readily available from local pharmacies unless the physician knows that he or she can opt out of allowing pharmacies to sell their information, as I described in a previous post.