Tuesday, September 1, 2009

Forest's Promotional Objective: Use CME to Sell Lexapro

We have known for some time that the actual purpose of industry-sponsored CME (continuing medical education) is to increase prescriptions of the supporter's product. But few will admit it. The ACCME says that it accredits only CME that is unbiased and objective, even though half of it is paid for by the pharmaceutical industry. Leading medical societies appear to be willing to fight to maintain their God-given right to industry funding of CME until the world ends.

Finally, a major drug company--Forest Laboratories--has confirmed that CME is, in fact, advertising.

In today's New York Times, Gardiner Harris describes a smoking gun document that outlines in stark fashion how Forest has created CME programs for physicians in order to increase market share for Lexapro. The document, entitled "Fiscal Year 2004 Marketing Plan," can be read in all its inglory here.

Here are a couple of my favorite excerpts.


• Achieve first place in detail dollar share of voice in the SRI market
• Maintain SRI category leadership in number of journal ad inserts
• Maintain SRI category leadership in total number of medical education events (Including CME symposia, speaker programs, teleconferences, and peer selling programs.)
• Generate significant Lexapro specific news coverage to both consumers and healthcare
• Have Lexapro included in all depression/anxiety related round up articles/stories that
discuss treatment"

Yep, there it is, number three on their list of strategies: CME symposia. But like any successful company, Forest leaves nothing to chance. In order to make sure that Lexapro-friendly CME got in front of potential prescribers, they came up with a variety of tactics, such as:

"A reporter from publications like CNS News, Psych Times, and the Journal of Clinical Psychiatry will be sent to cover key Lexapro data presented at important medical meetings. Data from ADAA (Anxiety Disorders Association of America), APA (American Psychiatric Association), AAFP (American Academy of Family Physicians, and AAGP (American Association for Geriatric Psychiatry) will be reported in the journal as a CME supplement.

Cost per unit:$75,000
Estimated Cost: $300,000"

In other words, rather than waiting for doctors to decide to write their own articles singing the praises of Lexapro, Forest decided to hire reporters from journals to cover the CME symposia they already paid for. Based on the reporting, ghostwriters would then scribble the articles, and plant some psychiatrists' names as authors. The articles would be packaged as "CME supplements" with the journals.

It's so much more...efficient this way!

There's more in this document, much more. Please give it a read, but I suggest you do so on an empty stomach.


Cetamua said...

I don't need an empty stomach. There was a time when I could enjoy fine dinning and wine while doing the bidding of these corporations.

In retrospect, I realize how easy it was to kid myself.

I find solace in the saying from Super-trader Marc Minervini: "Being wrong is acceptable, staying wrong totally unacceptable."

Anonymous said...

While I don't dispute the advertising intentions and improprieties of big pharma, I can't help wondering the following of Dr. Carlat:

1. Do you currently or have you ever participated in any CME programs funded by pharma?

2. Do you currently or did you ever meet with pharmaceutical sales representatives in your office, hospital or any other location?

3. Did you ever ask for, sign for or receive any samples of any medications either for personal use, family use or patient use from any drug company?

4. Ever allowed a breakfast or luncheon to be sponsored in your office by a drug company representative?

5. Ever attended any dinner, presentation or conference which was in any way and to any degree funded by pharma?

6. Ever played golf, attended a show, or participated in any event or entertainment paid for by a drug company during the course of a meeting, conference or convention?

7. Have in your possession any pen, sticky note, clipboard, clock or any type of item with a drug or company name on it?

8. Ever accepted any gift from a drug company while in medical school or as a resident or intern?

9. Ever accessed any of the drug companies' assistance programs which provide free or reduced-price medications to patients with financial need?

Just curious.

Daniel Carlat said...

Anonymous--Sounds like you're looking for a confession. See my article in 2007 in NY Times Mag, Dr. Drug Rep. (http://www.nytimes.com/2007/11/25/magazine/25memoir-t.html)
In 2002 I was a promotional speaker for Wyeth and Forest until I realized that I had become a drug whore and quit that sordid trade.

Anonymous said...

I'm looking forward to getting more of my manuscripts published, now that pharma won't be clogging up the publishing works with all their ghost-authored articles!

SteveM said...

I'm looking forward to getting more of my manuscripts published, now that pharma won't be clogging up the publishing works with all their ghost-authored articles!

That actually leads to an interesting segue. The elephant in the living room of bio-psychiatry is that many (most?) of the pyscho-pharmaceuticals have mediocre efficacy and fairly lousy side effect profiles. But those significant shortfalls have been effectively camouflaged by the Pharma propaganda machinery for years.

With paid shilling gone,few psychiatrists are going to want to publish conclusions that marginalize the specialty. Especially because so many have forgotten how to practice holistic psychiatry. Or were never skilled to begin with.

I mean for many docs, apart from script writing, what therapeutic value do they add? Schatzberg - empathic listener? C'mon... Honesty in drug evaluation would write a bunch of those guys out of a job.

Without Pharma generating content, perhaps you're looking at journals with only 2 articles per issue. (Apart from the DSM-V kerfuffle and the I'm-not-a-pimp denial bombs that psychiatrists are now throwing at each other.)

bmartinmd said...

BTW, do you realize that your Google ads link to pharma-supported CME?

Daniel Carlat said...

Yes, if pharma-supported CME companies think they can attract customers from a site like mine, which is explicitly anti-commmercial CME, they are welcome to try. These are clearly ads and not ads disguised as articles.

skillsnotpills said...

Personally, I see it as a bit hypocritical to turn to pharma advertising at your site. You can split hairs about it not being CME disguised advertising, but in the end, aren't you asking for accountability with medications accessibility and the message being forwarded by responsible parties, ie physicians and other health care providers, who can be accountable for consequences if offered in a manner less than savory?

Are you supportive of DTC advertising? If you are, that is disapppointing to learn.


Daniel Carlat said...

Skills--I hear you. It certainly appears unseemly for advertising to appear on a purist blog like mine. But until readers are willing to pay for internet content (which is probably never), advertising or individual passion to get the word out will pay for it. I've got the passion, but I'm experimenting with advertising. So far, after one week, I've made a grand total of $11.15. I'm not clear why it is unethical for me to allow advertising on my site. I believe in the free market and I support the ability of companies to advertise. If they choose to advertise on my site, I see no problem with that, within certain limits. I wouldn't allow ads for products that I believe are always bad for people, such as cigarettes. But industry-supported CME, and medications, are certainly not always bad for people, though either one can be in certain instances. I would like to see an end to industry-supported CME because I don't believe it can ever be well regulated. But there are some cases, especially those that are funded by multiple companies, in which industry-funded CME is not terribly biased, largely because the educators are scared of saying anything particularly good or bad about any product.

Anonymous said...

I applaud SteveM's comment. An article in the recent Clinical Psychiatry News asks that the psychiatry field "take back" psychotherapy training from the Non-MD specialites and that psychiatrists should be the "leaders" of psychotherapy! LOL. Nobody robbed academic psychiatry of psychotherapy training. They abdicated it in their quest to be bed buddies with Big Pharma. Of course the PHD and LCSW programs now corner the market on therapy -- why they are TRAINED for it! Psychiatrists these days are pill pushers -- and nothing more. They did it to themselves.

Anonymous said...

Even though you and I may not think industry sponsored CME is always bad, there are some in the CME business who apparently don't have a very favorable opinion of you.

See http://www.policymed.com/2009/08/carlats-blissful-deception.html

If you do a search of your name (Carlat) on his site you will find a number of unflattering articles about you.

Something else I found on this site is that this CME document about Lexapro is not the first one released by Congress documenting the pharmaceutical industry's abuse of the CME process to inappropriately push psych drugs.

Apparently Sen. Grassley released documents detailing how Glaxo used CME and specifically how they apparently paid Dr. Nemeroff of Emory to push Paxil under their Psychnet CME program.

See http://www.policymed.com/2009/02/letters-from-grassley-hhs-oig-investigate-emory.html

and specifically click on:

OIG Letter PsychNet Attachment 2-24-09


packet of information

More details on Nemeroff's payments from Glaxo under the Psychnet CME program may be found at:


and 36 additional documents can be found at the Senate Finance Committee's Website.



- A frequent contributor to Shearlings Got Plowed (a blog on Schering Plough and now Merck)

Go go there and read some of my stuff on Asenapine (More deadly than Zyprexa in my opinion)

Anonymous said...

On closer examination. It appears the Paxil Psychnet presentations are technically considered promotional. However the Psychnet document shows how closely these promotional speeches (including the topics) are comingled with related CME which ar also given by the same local KOLs and apparently paid for by Paxil's manufacturer. Plus it also notes how the company provides additional slides on off-label uses in case questions are asked. (Of course apparently paid for by SFK/Glaxo). Plus even though the document purportedly comes from Nemeroff and the other advisory board members it still is apparently paid for by SKF (Glaxo) and produced by Scientific Therapeutics Information, Inc..

Looks like a lot of blurring of lines to me.

It seems to me that if something is so difficult to tell whether it's within the law or not then it's problematic.


bmartinmd said...

Just to clarify:

My implied criticism doesn't refer to blog advertising in general. (God knows, I use Google ads at my web site--the challenge being to weed out the more offensive ads, like those for "complementary" therapies.)

My point is: Your Google ads specifically promote pharma-funded CME--your disgust for which has been an undying mantra. That creates a BIG disconnect in your message.* It's like a sobriety blog advertising alcohol.

If your rebuttal is that the ads have provided you with very little income to date, then that's also an argument for dumping them.

* Although now you state that not all pharma-funded CME is necessarily bad.

SteveM said...

Re: "It seems to me that if something is so difficult to tell whether it's within the law or not then it's problematic."

The hell with within the law or not. The more basic question is whether the CME content passes the laugh test.

Here's link to a Psychiatric Times CME course slide deck on Fibromyalgia:


The presenter (Danial Goldenberg) is a consultant to Eli-Lilly. And he does a fantastic backhanded pimp job for Cymbalta by bashing the side effect profile of its nearest competitor Lyrica. Without mentioning the equally bad (or worse) profile of Duloxetine.

Goldenberg's material is so explicitly sloppy, whether he was paid by Lilly or not is immaterial regarding the content. No, the real issue is editorial oversight. Where is the quality control and review of this stuff before it goes out?

One has to assume that the physicians with editorial oversight of the course would have experience treating Fibromyalgia so would would know that Duloxetine use can be very problematic. So would instruct the presenter to include that factually in his content.

I mean, if I were an unbiased doctor-reviewer who knew which way is up, I would have told Goldenberg his slides didn't pass the laugh test. And make him fix them before they went out.

Do those guys actually exist?

Daniel Carlat said...

Thanks, bmartinmd, for trying to keep me honest! I have been trying to block ads from companies that are "pure MECCs", that is, companies that are organized purely in order to make money by soliciting commercial grants for CME. Some of these companies might escape my attention, and I invite you and others to tattle-tale on such ads.

There are certainly some companies trying their best to ween themselves off of commercial support. Of course, even ACCME's new "transparent" list of ACCME providers is not very helpful in determining which companies are highly dependent on commercial support. 81% of all ACCME accredited providers report receiving commercial support, but there is much variation in the degree of the providers' dependence. Nor is this list accurate, since a casual inspection of the 19% of providers claiming no commercial support reveals that several do, in fact, accept such support.

Bottom line: any publisher which decides to pick and choose among advertisers based on some ethical standard has its hands full. It's not the easy way to make money.

Anonymous said...


The material I was commenting on was NOT CME. My point was it was just so hard to tell that it was clearly promotional and not CME.

So the fact that even after I pointed this out you made the same mistake I did supports my point that when clearly promotional stuff looks too much like CME it's a problem.

So I thank you for helping me by making the same mistake I did.