Current Psychiatry: Guess the CME Sponsor!

Yes, it’s time for your favorite game show, Guess the CME Sponsor.

Today, we have a special treat for you, a supplement from Current Psychiatry, entitled “Diagnosing and Managing Psychotic and Mood Disorders.” It is accessible online here.

The rules of this game are simple: No peeking to see which drug company has paid for the preparation of the supplement (so skip page 2).

Let’s start, shall we?

This supplement is composed of four case studies. As we know from past experience, medical education communication companies (MECCs) increasingly use case studies to communicate a marketing message in CME. Medscape did this so blatantly once that BusinessWeek published an article about it.

Both Medscape and Dowden Health Media (publisher of Current Psychiatry) love to use cases because they offer so many avenues for promoting the sponsor’s drug. There are usually three phases of promotion:

Phase 1: The case begins with a patient doing poorly on medications. This “bad” medication regimen is strategically chosen by the MECC to cast competitors in a poor light.

Phase 2: The “faculty” members (most or all of whom are consultants or speakers for the sponsoring drug company) then discuss the case, ostensibly in order to come up with ideas for how to improve the patient’s treatment. Here, the MECC can choose to highlight themes to accentuate advantages of the sponsor’s drug and shortcomings of competitors.

Phase 3: Finally, there is a dramatic denouement, in which the faculty decides on a better medication regimen. Obviously, MECCs will ensure that the rescue regimen incorporates the sponsor’s drug. If they are good at gaming this system, they will try not to make this blatantly obvious. As we’ll see below, Dowden Health Media has a lot to learn about subtlety.


Case 1: Treatment-resistant psychosis and schizophrenia

1. Initial unsuccessful medication regimen: Risperdal Consta, haloperidol decanoate, valproic acid.

2. Faculty discussion:
--Is the patient’s diagnosis of schizophrenia accurate? The faculty decides that the patient may actually have either schizoaffective disorder or bipolar disorder.
--They discuss the bad side effects of first generation antipsychotics, such as EPS.

3. Rescue medications: Start clozapine, stop haloperidol, and increase Risperdal Consta.

Comment: Janssen’s Risperdal Consta jumps out at us, because the rescue regimen involves increasing the dose as well as starting clozapine. However, it would be hard to imagine Janssen being happy about a case in which a patient starts by doing poorly on their medication. The faculty dwells on disadvantages of older antipsychotics, seemingly in order to lay the groundwork for the promotion of one of the atypicals, but at this point, we don’t know which one they will favor. Clozapine is available as a generic, so is not sponsorable. At this point, the only thing we can be fairly certain of is that Janssen is not the sponsor of the supplement.

Case 2: Psychosis with bipolar mania

1. Initial unsuccessful regimen: Risperdal and valproic acid; Risperdal was stopped because it wasn’t working, the patient was switched to Zyprexa, which helped a bit but caused 18 pounds of weight gain in one month.

2. Faculty discussion:
--The patient was initially misdiagnosed with ADHD and depression, but actually had bipolar disorder; initial use of stimulants may have precipitated a manic episode. (The message here is: “Diagnose more bipolar disorder.” This is a common industry CME tactic, in which experts harp on how the diagnosis for which the sponsor makes a drug is often missed. After all, the sponsor can’t make money unless the condition is liberally diagnosed.)
--Zyprexa is bad. To quote Dr. Pariser: “Olanzapine is a very effective atypical antipsychotic, but weight gain is a major concern for many patients receiving this drug as well as clozapine. I have observed that many patients who gain weight tend to go off the medication, and those who do may not always admit that they are nonadherent.”

3. Rescue regimen: Lamictal, topiramate, and an un-named medication that Dr. Goldberg coyly describes in these terms: “another atypical antipsychotic with a somewhat lower risk of metabolic side effects, relative to olanzapine, as well as an indication for treating bipolar depression to help lower the risk of suicide in this high-risk patient.” Which medication might Dr. Goldberg be referring to? Well, there are only two FDA-approved medications for bipolar depression: Symbyax (Zyprexa combined with Prozac), and Seroquel. Since he specifies that the best choice would not be Zyprexa, he must be referring to Seroquel.

Comment: The sponsor sure ain’t Eli Lilly. Any MECC that would take CME money from Lilly and then feature a case in which Zyprexa caused an astonishing 18 pounds of weight gain in one month would never see another dime from Lilly again.

While lamotrigine and topiramate were part of the rescue regimen, they are both generic, so unsponsorable. The rescue antipsychotic was Seroquel, so after two cases, my best guess is that the sponsor is AstraZeneca, maker of Seroquel.

Case 3: Bipolar depression and anxiety

1. Initial unsuccessful regimen: Effexor XR and clonazepam

2. Faculty discussion:
--Patient was misdiagnosed with depression; actually had bipolar disorder and OCD (diagnose more bipolar!)
--It can be difficult treating bipolar disorder when combined with anxiety. But Seroquel may actually be a good choice for both! To quote Dr. Goldberg: “Given data from studies of generalized anxiety disorder and quetiapine’s ability to reduce anxiety symptoms in the context of depression, using this drug alone might be safer than augmenting with sertraline and be just as effective as the combination.”
3. Rescue regimen: Seroquel, lamotrigine, and sertraline.

Comment: Looks like the MECC is pushing Seroquel for anxiety in anticipation of a possible indication for generalized anxiety disorder. Both lamotrigine and sertraline are generic and unsponsorable.


Case 4: Depression and anxiety: Distinguishing unipolar and bipolar disorders

1. Initial unsuccessful regimen: Sertraline, then Effexor XR.

2. Faculty discussion:
--Yet another patient with bipolar disorder misdiagnosed with depression—I guess there’s an epidemic of this. Funny how the faculty neglects to cover the evidence indicating that bipolar disorder may now be over-diagnosed.

3. Rescue regimen: Seroquel and lamotrigine.

Comment: C’mon guys, Seroquel again? Would it kill you to be subtle?

Conclusion

Let’s go through the possible sponsors.

Janssen: No, because Invega was not mentioned, and in one case, Risperdal Consta was ineffective at the starting dose.

Eli Lilly: No, because Zyprexa was never used as a rescue medication, and one of the cases featured the worst example of Zyprexa-induced weight gain that I have heard of.

Pfizer: No, because Geodon is never a used as a rescue medication.

Bristol-Myers Squibb: No, because Abilify is hardly mentioned at all.

My guess is that the sponsor is AstraZeneca, because in three out of the four cases, Seroquel is the linchpin of the rescue regimen.

Now for the fun part. Go back to the supplement, turn to page 2, and you’ll find that the sponsor is………AstraZeneca, maker of Seroquel.

Winners receive a lifetime supply of Seroquel. We are not responsible for fatalities, injuries, or loss of employment due to the sedation and weight gain caused by Seroquel. Employees of AstraZeneca and Dowden Health Media are not eligible for participation in this contest.