Monday, July 14, 2008

The APA and Drug Money: We're on it, Senator!

Senator Charles Grassley recently sent a letter to the American Psychiatric Association (APA) requesting detailed information on all of the organization's financing from drug companies. This received extensive coverage in the New York Times, as well as other media outlets. For those interested, the APA sent out this email to its membership about the issue (reproduced on Pharmalot--scroll down on their site to see it).

I find myself in the unfamiliar position of being an APA insider regarding this issue. I was appointed by the current APA president, Dr. Stotland, to the work group she alludes to in the Times article. I announced this work group in a prior post. It was formed in March, and its official mission is:

"The formation of an ad hoc work group of the Board [meaning the Board of Trustees] charged to work with the Medical Director to: identify the categories and amounts of monies received from the pharmaceutical and other industries producing products or services used in psychiatry by the APA and its subsidiaries; determine what direct and indirect financial consequences there would be from discontinuing each category; indicate how the APA could adapt to the attendant change in revenue; and to provide the Board with the elements of a 5 year plan to end or diminish the pharmaceutical revenue received by the APA. The ad hoc work group will report to the BOT with a report and recommendations by October 2008."

So, in defense of the APA, they were already getting quite serious about examining the influence of the pharmaceutical industry well before Grassley's letter. All members of this work group were asked to sign a confidentiality agreement as a condition of participation. I thought long and hard before signing, and ultimately decided that I could be more helpful to the cause of honesty and transparency in the APA by signing and participating than by walking away.

Therefore, I can't reveal any specifics of the work group's discussions. But more generally, I can say that I have been impressed by the thoughtfulness of the discourse. Everybody realizes that this issue is a serious one for the organization, and some sincere, determined work has gone into the deliberations thus far.

Meanwhile, on a related note, over at the arch-conservative pharma-funded site, Drug Wonks, Robert Goldberg rants about Grassley's "obsessions," using the tired and worn out argument that since Grassley himself receives money from companies (imagine, a U.S. Senator receiving campaign contributions from companies and lobbyists, how shocking) he has no business calling the APA or anybody else on the carpet about their finances. Of course, the issue is less the money itself, but rather the need for transparency. The next time somebody feels the need to call Grassley or anybody else a hypocrite, I suggest you check out the Open Secrets website. Here, can read all the financial details you can stomach of anyone in the Congress or the Senate. Not only are legislators required by law to reveal the amounts and sources of all campaign contributions, but they must also reveal everything about their personal finances. Physicians have it a little easier than this.


Anonymous said...

Dr Carlat:

In response to your appraisal that the committee was formed before the Grassley action, isn't it possible someone in the APA of political clout with Congress got wind these matters were coming down the proverbial pike and were being preemptive to be defensive or manipulating the reaction?

just a guess, but let's be honest, politics is in pretty much every endeavor of society. And, your honesty is appreciated, but with what you have said, doesn't that now exclude you from reporting on this matter? You are not unbiased and objective anymore, in my opinion. For me, I feel it validates my earlier opinion you were recruited as much to take you out of the debate as to give any alleged credibility to the committee to begin with.

I hope I'm wrong. But, I'm jaded and cynical with the group at hand here, so I know I am not objective and unbiased. Trust is earned; there is little the APA has done in the past 13 years to give me a sense to take renewed risks.

Sorry to write this, but it's what I feel and sense.

Anonymous said...

I agree with therapyfirst. In researching who was on the Ad Hoc Working Group with Dr. Carlat, I learned that (presumably since March 31, 2008 when he here denied membership) Dr. Carlat now serves on the APA Committee on Commercial Support, which I guess he forgot to mention today. So he is not just an insider, as he says, but a double insider!

This is a permanent component of the APA, and appears to be Dr. Carlat's first step on his climb to APA Valhalla. As an APA committee member, he will be treated to a free trip to D.C. this fall. Congratulations, Dr. Carlat, I am glad to see that you, Dr. Stotland, and Dr. Schatzberg are "on it."

My guess is that your work group will be in very close touch these days with the APA Trustees. If you and your APA stalwarts are really "on it" you will urge Dr. Schatzberg to resign immediately as APA President-Elect, for the good of the APA, and for the good of the mentally ill. Psychiatry's public image is quite low at present, I imagine, and Dr. Schatzberg's continued leadership of the profession will only degrade us further in the public eye, and deter people who could use our help from coming to see us.

Dr. Stotland has begun circling the wagons--the APA will do nothing, she said, against Dr. Schatzberg. It is up to the membership to somehow try to keep our profession from becoming a worse laughingstock. This is not a matter of innocence or guilt before a court, where a presumption of innocence might warrant keeping Dr. Schatzberg on. Whatever kind of spin Dr. C might like to put on it, this is APA's lowest moment in history. Perhaps these various groups Dr. Carlat is on might take an altruistic perspective, and help save American psychiatry.

Will you help us Dr. Carlat?


Anonymous said...

You have to really love how the APA swallowed Stanford's explanation. Here's something the APA obviously didn't consider.

Stanford’s statement: “We would like to underscore that Dr. Schatzberg has not been involved in managing or conducting any human subjects research involving Mifepristone, a pharmaceutical that Corcept licenses for the treatment of psychotic major depression.”

I guess APA leadership never learned how to search PubMed.

Here’s a Schatzberg study of "human subjects research involving Mifepristone" in 2003: “Mifepristone versus Placebo in the Treatment of Psychosis in Patients with Psychotic Major Depression.”

Another in 2006: “Clinical and biological effects of mifepristone treatment for psychotic depression.”

Anonymous said...

I agree with therapyfirst: I think APA did a masterful job of effectively silencing you on this issue, Dr. Carlat. I admire your work -- but I smell a rat. But you are credible, so I will have to trust your post that the internal APA discussions are "sincere." I wonder if such discussions will remain so once the new APA President assumes control. You know, the guy from Stanford who seems most interested in protecting his stock investment in a company trying to market an ineffective pill that will no doubt soon be advertised on the pages of the American Journal of Psychiatry as a "wonder drug" for psychotic depression! I apologize upfront for my cynicism. Keep up the good work -- if you can.

Psychiatrist in Iowa said...

I believe that Goldberg's concerns criticisms of Grassely are valid...his connections to contributers are indeed questionable. But this is a red herring and it doesn't mean that Grassley is wrong to expose the physician/Pharma cabal.

Either Goldberg is trying to discredit a very effective critic, or he is suggesting that influence peddling should be acceptable for physicians as long as politicians are doing the same.

Personally, I don't care how dirty Grassley is. I just love seeing him turn up the heat. Bring it on Senator!

Anonymous said...

Regarding IowaDoc's last posting above:

You really should be wary of Grassley being influenced by outside sources in this investigation, because if it is being prompted by an equally nefarious group of people, it will take the wind out of any true sail that needed opened in the first place.

As an example (not a truth but a suspicion to me for now), if influential Scientology members got ahold of the information that is driving Grassley's proceedings, and it turns out these people contribute to his election funding, and that gets exposed by influential psychiatric members to thwart further investigations, everyone looks like an idiot but the details get lost among the fingerpointing and innuendos, and the public is failed once again as the needs of the few screw the needs of the many.

Dirty people love to drag others into their muck to diminish the impact of real concerns. Frankly, the way this is all playing out only reinforces I am glad I do not belong to the APA and have to wonder why responsible, ethical people, who I consider Dr C one of them, would continue their membership with Dr Schatzberg likely to be president in 9 months.

This matter will embarass psychiatry for some time, and I can only speak for myself, but participating at another blog that is full of antipsychiatry zealots who are eager to watch this situation just compound itself, I do not need clueless and immoral colleagues ruining the cause of my profession for what is fairly obvious just for a buck.

If we can't police our own, we look stupid at the very least to have to expect others, who don't know the nuances and specifics to how to responsibly practice health care, to manage us. The APA is a joke, the ABPN marginalizes us by not making everyone go through recertification, State Boards responsible for credentialing and conduct are inept at punishing true and repeated offenders, and colleagues within communities just look the other way at incompetent and reckless behaviors in care.

You wonder why we have lost clout and capital in the past 20 some years? We as doctors played a sizeable role in it ourselves. There is no excuse for corruption, there is no excuse for carelessness, and there is no excuse for ignorance.

Anyone reading this who is a physician, talk to your colleagues and voice your concerns.

take a stand, or sit down and shut up when the consequences play out!

Daniel Carlat said...

There's no question that I feel the need to be somewhat cautious in my remarks regarding this particular issue. That's not a situation I often find myself in! That said, I genuinely am hopeful that the work group will end up accomplishing some real reform within the organization. At any rate, once the APA replies to Grassley, everything will be suddently quite public and I'm sure the discourse will be free-wheeling and highly interesting.

Anonymous said...

So the guys at the pharmaceutical front group Drug Wonks argue that someone might be influence by corporate money.

Really!? I wonder who that might be?

Psychiatrist in Iowa said...

The political system actually suffers from the same maladay as the Medical Profession. Both have gotten themselves hopelessly intertwined with coporate special interests, and both have convinced themselves that this corruption is a necessary evil that must be endured in order to accomplish their goals. They are more than willing to buy into insidious suppositions like "this is how it's always been done" and "everybody does it".

Call me a Pollyanna if you must, but I remain hopeful that there will be change after the election. Obama seems to be drifting a little toward the status quo and McCain certainly isn't the maverick he used to be, but either of them would be a huge step in the right direction compared to where we are today.

In the end though, the PEOPLE have to want this change. If they continue to believe that "What's good for GM is good for America" then they can just as easily believe the same about Pfizer and Lilley.

Psychiatrist in Iowa said...


I will admit that perhaps I have a different perspective on Scientologists since we have very few (if any) of them in Iowa. But I remember what it was like when I trained in a larger city and they were slinking around in the media and the statehouse. It can make a mental health clinician a little paranoid.

The national perception of Scientology appears worse than ever from what I can see (thanks in large part to Tom Cruise). They seem to be regarded by the average citizen as a crackpot cult that should be allowed to exist but that should not be taken seriously. I think that most folks in our country recognize the need for and value of mental health treatment.

However, at the same time, I think that Scientology raises some valid points that cannot be completely dismissed (overuse of restraints, overmedication of kids, etc.). I'm sure that Senator Grassley's staff is capable of ferreting out the nonsense and focusing on the credible issues.

If he has any bias, it is against drug companies, not psychiatry. He has taken on other issues in the past that irritate Pharma as well. That's a bias I can live with, because it serves as an important part of our checks and balances. Somebody needs to be out there as a countweight to the enormous influence that this industry has.

What you are seeing my friends is democracy in action. Pull up a chair, turn up the volume and enjoy!

Anonymous said...

I'm asking the following questions not to be contentious but because I'm pretty sure there are answers I haven't thought of, so here goes:

Why is it that it is automatically assumed that taking money is the problem? If the research turns out to be okay, I'd assume it wouldn't matter where the money came from. Think about it this way, if bottled water company A claimed it had found the fountain of youth and bottled water from it to sell and it turned out to really be the fountain of youth, it would be instantly obvious and the inquiry wouldn't be into how much the Standford University Water Dept. Prof who tested it got paid to do the testing.

Isn't the real problem here not that the APA or any individual or university took money from a corporation but instead that these the individuals the corporation paid to do research fudged it? And that they fudged research in a way that made it appear that harmful drugs with little theraputic value were sold as miracle cures? If Paxil or zyprexa was really a miracle cure with no known side effects would anybody really give a damn how much the apa got paid for advertising these drugs in their journals?

Who is better suited than a psychiatrist to run a study regarding whether a psych drug works? (not an entirely rhetorical question). Do Pharma Corps have inhouse r & d departments that develop drugs before the drugs are released to the outside psychiatrists for testing? (I assume yes). Is it wrong for Pharma to want psychiatric drugs to be tested before they start selling them to the public?

If Grassley takes Big Pharma bucks and he's looking into this couldn 't it be that say Glaxo is upset about taking the fall for Keller's bogus Paxil work, or on the other hand will Keller and Biederman and the APA all try to claim it's big pharma's fault? If the APA is letting big pharma money stand in the way of peer review is that really so surprising? Shouldn't that be the job of some watchdog group like the NIH (okay owned by big pharma, I assume) or the FDA (who do a crappy job of monitoring everything from advil to zyprexa)?

Is the money the problem or is there some systemic problem?

soulful sepulcher said...

If Dr.Carlat signed a confidentiality contract, certainly would HOPE HE KEEPS IT. In this case who can expect him to write exactly what's happening behind the scenes?

Hell, it's about truth and honesty isn't it?

I actually expected him to remain silent on the topic.

I'm personally glad to see Grassley take on this and the other issues, and I hope the pressure remains where it should:

On the APA, the Universities, the Biederman et al team who forgot somehow they earned a million or so extra bucks ----

I'm still waiting for public disclosure of the internal investigation of that Biederman topic.

Until then, all of these fires have been lit and I for one am glad to see it happen.

Anonymous said...

Dear Dr. Carlat,

I think you should be commended by expressing your viewpoints in the venues that are appropriate for polital and peer review.

I support your freedom of speech to blog, but acknowledge your hard work for the APA (I do NOT think you get a free trip to the APA annual meeting, most APA members on such committees DONATE their time and pay their own way to serve).

Discussion is good in general. Your blog is interesting, entertaining, and might stir some curiosity. Meaningful change usually occurs with collaboration, hard work, mutual respect, and compromise. Kudos to you for your APA work.

Best wishes
An APA member and Fellow Psychiatrist

James M. La Rossa Jr. said...

To Anonymous' posting of July 16, which begins: "I'm asking the following questions not to be contentious but because I'm pretty sure there are answers I haven't thought of ..." This is a rather brilliant contribution. Your take-home point seems to be that it may not be the money that results in the "fudged research."

You ask, "Isn't the real problem here not that the APA or any individual or university took money from a corporation but instead that these the individuals the corporation paid to do research fudged it?" And, thus, Is the money the problem or "is there some systemic problem?"

While I am not positioned to give your question the thought it deserves, I feel I can be of some use by drawing some attention to it. This is a most obvious point that we seem to ALL be ignoring. While we are hyper-critical of industry sponsorship and the rules that have made this pro forma, the named researchers have been taken to task, for the most part, about the money they have made and NOT the veracity of the research itself. Whether the issues are or are not part and parcel of one another is another element to consider. Thank you.

Anonymous said...

This is great! Even more drugs, even more money! Psychiatry some times sucks. I've linked to this article and I've written a few things myself if you want to see at