Monday, December 22, 2008

Current Psychiatry CME: Looks like an Ad, Smells like an Ad...Yep, It's an Ad

In Dr. Goldberg’s response to my “Guess the CME Sponsor” parlor game, he is defending the accuracy and balance of his article. However, I never questioned the accuracy of the Current Psychiatry supplement.

The supplement is both accurate and is a veiled advertisement for the use of Seroquel in the treatment of bipolar depression.

Commercial bias and accuracy of content make excellent bedfellows, because accurate and academic presentations of material give the articles exactly the aura of legitimacy that the sponsor is purchasing.

The Current Psychiatry supplement was entitled “Diagnosing and Managing Psychotic and Mood Disorders,” which is an extremely broad topic. There are hundreds of approaches one might use in covering the topic.

For example, one could focus specifically on depression with psychotic features, in which you’d emphasize the overall superiority of ECT, while also covering a variety of combinations of antidepressants and antipsychotics.

You could focus on treating mood problems as they arise in schizophrenia, most commonly depression and suicidal ideation. Such an article (here is one example) would focus primarily on antidepressants.

You could focus on treating psychosis in patients with risk factors for cardiovascular disease, in which case you would talk about Abilify over and over again, as happened in this recent CME supplement sponsored by Bristol-Myers Squibb, and published by the Journal of Clinical Psychiatry.

You could focus on the treatment of acute mania, in which case you’d pretty much have to give equal airtime to all the atypicals and the mood stabilizers.

But, in 3 of the 4 cases presented, Dr. Goldberg and colleagues chose to focus their attention on the treatment of acute bipolar depression. It just so happens that Seroquel is one of two treatments FDA-approved for bipolar depression. It just so happens that AstraZeneca funded the supplement.

Of course, the “it just so happens” part is the core of the problem. There was nothing random about it. The authors knew exactly who was funding the supplement, and they chose to highlight the advantages of Seroquel because of this.

If you take great care in choosing the topic, you can always find one that will inevitably highlight the sponsor’s product. This is fine, as long as it is clear to the readers that it is a promotional activity. For example, on the website, there is plenty of accurate information about the advantages of Seroquel for bipolar disorder, including a case study similar to the cases presented in this supplement. This is an excellent source of information for those interested in learning about patients for whom Seroquel is helpful. But it’s an advertisement, festooned with Seroquel logos. It is transparent, and it is honest.

The Current Psychiatry supplement is neither transparent nor honest, because it holds itself out as being accredited Category 1 CME. ACCME criteria are explicit that accredited CME cannot be crafted in order to endorse the sponsor’s product. Specifically, this supplement violates Standard 5.1 of the ACCME’s Standards for Commercial Support, which states: “The content or format of a CME activity or its related materials must promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.”

This is the point in the debate where defenders of commercial CME will argue that this not conflict of interest, but rather “convergence” of interests. AstraZeneca gains by showcasing Seroquel, and the physicians gain by learning about a good treatment. But this is called advertisement and promotion, not CME. If the Current Psychiatry supplement had been preceded by the statement, "The following is a product advertisement funded by AstraZeneca," there would be no controversy about it at all.

Getting the ACCME seal of approval is supposed to mean something. It means that the educators have one single agenda in mind: helping physicians sort through the complexities of diagnosis and treatment in order to do the right thing by their patients. The Current Psychiatry supplement, however, was written with two agendas: educating practitioners and selling Seroquel.


Anonymous said...

As always, a fair-minded and brilliant retort, Dr. Carlat. That's why my residents in psychiatry tell me how much they admire you. Keep up the good work. There is hope in the minds of the emerging generation of psychiatrists-- in no small part, due to your effots!

Anonymous said...

Ah, fair-minded and brilliant indeed. Do you think that 'emerging generation of psychiatrists' will still have such hope, when they realize they're stuck with the same woeful drugs we have today? The witch hunt, with its puzzlingly strange bedfellows (Carey, Carlat, Grassley, and the scientologists - who knew?), will ultimately leave us bereft of clinical investigators in academia, as the risks of working collaboratively with industry have simply become too high. See how you like it when pharma calls *all* the shots. Another decade of seroquel? Perish the thought.

Here's a tip for those hopeful residents in the meantime - if you want decent review articles, why are you reading nonsense like Current Psychiatry or JCP supplements in the first place? AJP, Archives, and a few others have peer-reviewed review articles. And rather than being spoon-fed, how 'bout reading the literature? How 'bout *paying* for CME, and doing your homework by looking up the providers' funding sources, rather than expecting pharma to subsidize it? You get what you pay for...

And, while we're at it: "Therapyfirst"? Funny, I can't seem to find a good review article or CME course suggesting dynamic therapy for psychotic mood disorders.

Anonymous said...


Funny, I can't find a source to explain pathetic sarcasm either.

I don't know what is more annoying, posts like yours, or such posts getting approved to take shots at commenters who are invested in change, not just dragging down such efforts.

I will agree with you on one point, you get what you pay for. It is time for physicians to pay for quality CME, and for review boards who examine CME credits for renewal of licenses to scrutinize such alleged CMEs better.

Anonymous said...

Hey localdoc:
Nice inflammatory post. Dr. Carlat and Scientology? What’s next? Dr. Carlat and Tom Cruise are drinking buddies, with the tab being picked up by Senator Grassley and Jim Carrey??? Or maybe Jim Carrey is promising Dr. Carlat a role in a new blockbuster movie about Big Pharma? Go for it! Oh, and what planet do you live on? Big Pharma ALREADY calls the shots! That’s the problem! Your parting shot at therapyfirst about dynamic therapy for psychotic depression is a straw man’s (or woman’s) argument. Who would ever suggest that? To my knowledge, therapyfirst never posted such a comment. Oh, I know: Maybe the same people who are investors in our new APA President’s company Corcept which is marketing mifespristone -- an ineffective drug-- for psychotic depression? You tell me.

Anonymous said...

As usual, another crackin' column by Doctor C. I'm glad you're out there turning back the veil for those of us who are more easily fooled. We owe you.

Anonymous said...

Amen localdoc!

" The witch hunt, with its puzzlingly strange bedfellows (Carey, Carlat, Grassley, and the scientologists - who knew?), will ultimately leave us bereft of clinical investigators in academia, as the risks of working collaboratively with industry have simply become too high."

Strange bedfellows indeed, though it seems that Carlat's motives are more high-minded than Grassley's. Amazing how his motives go unquestioned, and he's the politician! Cognitive dissonance rules!

Anonymous said...

localdoc and gina pera probably think that Dr. Carlat is also tied to JFK's assassination... hmmm weren't Dr. Carlat and Senator Grassley both spotted on the grassy knoll?

modernpsychiatrist said...

a good well thought out reply , dr.c...
psych has been hijacked by big pharma and this and other similar "cme activities" no doubt shamelessly continue throughout the countrys residency programs, indoctrinating young infant psychiatrists to peddle their wares ! How can one possibly expect to win.................