Monday, July 30, 2007

Tweaking Medical Information, Courtesy of CME Zone

If I ever decide to chuck all this idealistic stuff and start taking Pharma money, I know exactly which ghost-writer I will hire first to create my million dollar CME programs: the genius who wrote a hopelessly biased tract for CME Zone called "Recognition and Treatment of Anxiety Disorders in the Primary Care Setting." I have never seen information more artfully tweaked in favor of a sponsor's drug.

You can access this article
here, but you will first have to register at I believe this was originally published in CNS News (November 2006), and is now being emailed to various physicians as a free CME activity.

To get a feel for how very good the ghost-writer is, you have to know that the generally accepted first-line treatment for anxiety disorders is one of the antidepressants, either one of the SSRIs or the SNRIs. The sponsor of this article, Schwarz Pharma, unfortunately does not market one of these first-line treatments, being saddled instead with Niravam, which is alprazolam orally disintegrating tablet. It's a fancy version of that old standby, Xanax.

Our ghost-writer starts the article with the usual information about how common anxiety is, and how important it is for primary care doctors to seek it out. This lays the groundwork for the crucial treatment section.

The "Treatment of Anxiety Disorders" section opens with Table 4, above. What's the first medication you see? Alprazolam. So what? There's nothing tricky here, it's simply an alphabetical listing of medications. is unless you consider the two major classes of medications for anxiety to be "antidepressants" and "benzodiazepines." If they had used this classification, the first drug listed would have been clomipramine, followed by escitalopram, and so on. Alprazolam would have been lost in the middle of the chart somewhere.

But this is minor stuff; it gets more interesting. Under "pharmacotherapy," the first paragraph is a glowing tribute to the power of benzodiazepines. Sentence number one:

"Benzodiazepines have been used extensively for the treatment of anxiety disorders since the 1960s; newer benzodiazepine formulations, such as extended release tablets and orally disintegrating tablets, offer alternative dosing and delivery options."

Thus, our ghost mentions the sponsor's drug right away. Next on the agenda: address the concern that patients can become addicted to benzos. Our ghost quickly describes two studies showing that most patients don't get addicted. Whew! I was beginning to worry that I might have to start my anxious patients on SSRIs after all.

Later, ghost covers both buspirone and SSRIs/SNRIs tepidly.

Buspirone: "Buspirone has been demonstrated to have efficacy in the treatment of GAD, but not in other anxiety disorders or depression." Later we hear about a head-to-head between alprazolam and buspirone in which alprazolam worked more quickly and produced fewer side effects.

SSRIs and SNRIs: One mechanical statement of efficacy ("...most agents in this class now have FDA approval for several anxiety disorders") followed by two gory paragraphs about how awful SSRIs are when it comes to drug-drug interactions (Niravam doesn't share this liability, of course).

There are many more instances of the Power of the Tweak, but I'll let you discover the rest. I wouldn't want to deprive you of your own thrill of discovery!


soulful sepulcher said...

What a gold mine, and I bet my PCP swears by this. This PCP has prescribed for me, per labeling me with "anxiety":
1.Alprazolam -1999
2.Xanax XR-2005
Once I brought up the word "Bipolar" [in 2006]he suddenly could not prescribe any of those meds to me any longer "due to THAT being out of my expertise."

Now tell me how a PCP can write so many RX's and for "anxiety" or "break through anxiety", as the labels all read. So Ghostwritten stuff like that is junkmail they take seriously-- for doctors who over-prescribe serious medications, wow.

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

Just curious... Why would the "first line of treatment for anxiety disorders" be an antidepressant instead of an anti-anxiety medication (e.g., a benzodiazepine)?

According to the Surgeon General ( ) anti-anxiety medications are, of course, regularly prescribed for anxiety disorders as a standard treatment. Your suggestion that they are somehow inferior to SSRIs or the like is simply your opinion (dare I say "bias"?) without citations to support the assertion.

Daniel Carlat said...

Anon, According to the most recent APA guidelines for the treatment of panic disorder: "SSRIs are likely to be the best choice of pharmacotherapy for many patients with panic disorder because they lack significant cardiovascular and anticholinergic side effects and have no liability for physical dependency and subsequent withdrawal reactions." (

Mother Jones RN said...

Hi there. I just found your blog, and I like what you're doing over here. I'm adding you to my blogroll, and I'll be back.

Mother Jones, RN

Anonymous said...


First, thanks for the response to Anon. Well done. And I am sure the citations used by the "ghost rider" (couldn't help it), if reviewed closely and objectively were all appropriate and the best science possible to support their argument (how do I know not?- oh see below). Curiously, many times I see physicians point out these type of "CME" things and among the first responses I see is that THEY must be biased for pointing this out. By the way, how many of the pharmas pass by your blog and try to find fault in what you write? I'd love to know.

As a primary care physician who once worked in the pharma industry, I must say that I routinely had to re-write/edit this type of "CME" or kill it altogether. Thank God that, for the most part, I had strong, ethical Regulatory, Legal, and other Medical people working with me. Now, I always check the source of funding for any "CME" pushed in my face. I recommend that and a good textbook/quick Medline search on the topic for any physician considering following the recommendations of any industry-funded "CME". Oh, and patients as well. Sorry but that's just the way it is, folks.

Dr. Mike

Anonymous said...

Thanks for referring me to a 9-year-old document on panic disorder, when your original blog entry was about "anxiety disorders," which includes panic, but many other types of disorders as well.

But if you're going to quote from the document, let's be fair to the document's authors, shall we? Taking one or two sentences out of context makes you no better than some of the people you write about:

"There are four classes of medications that have been shown to be effective: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), benzodiazepines, and monoamine
oxidase inhibitors (MAOIs) [I]. Medications from all four classes have been found to have roughly comparable efficacy [II]. Choosing a medication from among these classes is generally
guided by considerations of adverse effects and the physician’s understanding of the patient’s personal
preferences (including costs) and other aspects of the clinical situation [I]. For many patients, SSRIs are likely to have the most favorable balance of efficacy and adverse effects. Although SSRIs carry a risk of sexual side effects, they lack the cardiovascular side effects, anticholinergic
side effects, and toxicity associated with overdose that occur with TCAs and MAOIs. SSRIs also lack the potential for physiologic dependency associated with benzodiazepines. TCAs can be tolerated by most patients, although generally not as well as SSRIs. The risks of cardiovascular and anticholinergic side effects of TCAs should be considered, especially for the elderly or patients with general medical problems. Benzodiazepines may be used preferentially in situations in which very rapid control of symptoms is critical (e.g., the patient is about to quit school, lose a job, or require hospitalization). However, the risks of long-term benzodiazepine use, including physiologic dependence, should also be considered. Benzodiazepine use is generally contraindicated for patients with a history of substance use disorder. Although MAOIs are
effective, they are generally reserved for patients who do not respond to other treatments because of the risk of hypertensive crises and necessary dietary restrictions. SSRIs are likely to be more expensive than TCAs or benzodiazepines because of the lack of generic preparations."

Now here's the point I will highlight:

Medications from all four classes have been found to have roughly comparable efficacy [II]. Choosing a medication from among these classes is generally
guided by considerations of adverse effects and the physician’s understanding of the patient’s personal
preferences (including costs) and other aspects of the clinical situation [I].

So while it may be **your** preference to prescribe SSRIs as a first-line treatment, the guideline suggests that any one of the four classes could and should be prescribed, taking into account the **patient's** person preferences as well (you remember the patient, the person who you're there to help, don't you?).

Anonymous said...

Ghostwriting is not limited to the promotion of discredited medical treatments. Especially in psychiatry, where the most commonly used and endorsed treatments have been barely tested rigorously, most writing may be termed ghostwriting...
BZDs differ markedly from SSRIs in their short-term effects, i.e., alprazolam will usually produce some sedation and muscle relaxation within 30 minutes, compared to any SSRI. This is what makes them more appealing to prescribers, who feel pressured to provide "instant" relief when a patient complains of sleeplessness, worry, tension, etc.
SSRIs do not have this instant effect, and thus have to be promoted based on "educating" patients about their "chemical imbalances" and the need to stay on the drug for months and years to correct their "abnormal" brain...
Also, contrary to the Surgeon General's excerpt that you cited, SSRIs do carry the significant risk of unpredictable, complex withdrawal syndromes that appear less responsive to gradual taper than BZD withdrawal syndromes (which may themselves also be quite complex and long-lasting).
Ghostwritten or not, any recommendation on the treatment of anxiety should begin with the recommendation that non-drug interventions, including exercise, sleep hygiene, meditation, cognitively-focused therapy, and insight-based therapies, are much more preferable and less risky as first-line interventions for the vast majority of patients than any drug on the market today.

Daniel Carlat said...

I agree with both anon's that benzos work well for panic and other anxiety disorders, and that in certain patients they are preferable. But the point of my posting was not to argue this therapeutic issue; rather, it was to show that, depending on what the commercial agenda of the sponsor is, you will get a very different view of what the best treatment is for a given condition. Recent CME programs sponsored by Forest emphasize the value of SSRIs and barely mention benzos, while the CME Zone article I evaluated highlighted benzos. Until we ban industry sponsorship of medical education, we'll never know who to trust.

Anonymous said...

Dr Carlat,
Your blog site is full of energy. However, I take exception to your suggestion that the reader should consult a reliable source for treating anxiety, and that you provide a link ONLY to your journal which requires a paid subscription. The NIMH website, among others would be a useful resource. Please, let's provide some choice about where reliable information can be obtained to the greatest extent possible.
Bruce Lydiard