Biased Education: A Summer's Cornucopia with CME, LLC

I've been on vacation in New Hampshire for the past week, giving me an opportunity to appreciate summer's bounty. Now, getting back to business, I realize that the cornucopia doesn't end at a dinner table overlooking a New England lake. Throughout the world of commercial CME, there is enough pro-sponsor bias to leave us all sated, whether we are on vacation or not.

The first course of what will undoubtedly be a long summer feast of bias is provided to us by one of the largest medical education communication companies, named, aptly enough, CME, LLC. This is the dominant provider of commercial CME in psychiatry, publisher of Psychiatric Times and sponsor of the well-attended U.S. Psychiatric Congress, heavily subsidized by industry-supported symposia.

Recently, perusing the web, I came across one of their programs entitled "Bipolar University," a "lifelong learning initiative" set up in response to the "pressing need to educate clinicians about bipolar disorder."

Navigating to "educational components," I clicked on the first of several offerings listed, "CME Articles with Interactive Case Studies." I chose the first article, "A Case-Based Guide to Using Treatment Guidelines in Bipolar Disorder," by Trisha Suppes, MD, PhD and Deborah Kelly, MA. I invite you to visit this activity now, which will require a free registration process. You'll see that the point of the lesson is to teach us how to apply the Texas Implementation of Medical Algorithms (TIMA) to the treatment of bipolar disorder. For those who have not heard about TIMA, it is an updated version of TMAP, the Texas Medication Algorithm Project, originally developed in 1997 with funding from both the Robert Wood Johnson Foundation and several pharmaceutical companies.

You can already see that something fishy is going on here, because an article ostensibly about the general topic of treatment guidelines is actually an exposition of one particular, industry-friendly guideline.

At any rate, the article itself is a discussion of TIMA's recommended treatments for both bipolar mania and bipolar depression, illustrated by two case examples. In the first case, we hear about a 35 year old woman who presents with mixed mania, and is treated with valproic acid and risperidone to good effect.

The second case is where things get more interesting, and where our summertime feast of CME bias really begins. This is a 30 year old man with bipolar disorder, already on lithium monotherapy, who presents with symptoms of major depression. The patient is started on Lamictal, which is TIMA's first line recommendation for treating bipolar depression. However, unfortunately for GlaxoSmithKline (maker of Lamictal), the patient suffers unspecified "side effects" on Lamictal, and is therefore switched to AtraZeneca's Seroquel, and gets better.

Oh, did I forget to mention that this article was funded by AstraZeneca, and that Seroquel was just approved by the FDA for the treatment of bipolar depression, and that AstraZeneca is in the midst of a major marketing campaign to encourage its use for this indication?

Now, let's conduct an autopsy of exactly how this CME article is biased in favor of the sponsor's drug. Case studies are a favorite technique used by medical education communication companies, because they are a way of spotlighting a particular product without appearing biased. Thus, apart from the case studies, this article is a fairly objective, if bland presentation of industry-supported treatment guidelines. The first case study endorses valproic acid and Risperdal, neither of which are in direct commercial competition with Seroquel, since Depakote is available generically and risperidone is a lame duck for Janssen, on the verge of going generic and being vigorously supplanted by Janssen's "new" Invega.

No, the money for AstraZeneca is in getting Seroquel prescribed in favor of arch-rival Lamictal, which is itself being vigorously promoted in a series of GSK-funded CME programs (see my review of one here). The second case study takes place in a bizarre parallel universe in which patients have more side effects on Lamictal than on Seroquel, exactly the reverse of what we psychiatrists commonly see here on Earth. Unrealistic, perhaps, but it serves the sponsor well, telling the story of a patient who likes Seroquel. We don't hear anything about Seroquel's famous side effect of sedation, because that would reflect poorly on the company footing the bill.

Aah, the feasts of summer. Now I have to sit back to build up an appetite for my next course. Luckily, the menu offers of plethora of choices.