Nemeroff and Schatzberg's “Textbook” Pushed Paxil

So I finally got the book, ripped open the manila envelope from an Amazon reseller, and found out exactly what a $120,000 “unrestricted educational grant” will buy: an advertisement for Paxil. Not obvious, not blatant. But artfully crafted, subtle, smooth—more in the style of Nemeroff than Schatzberg. Nemeroff was clearly the mentor in this project.

Much ink has been spilled about whether the book was or wasn’t ghostwritten by a PR firm called STI. This letter from STI to Dr. Nemeroff appears to be a smoking gun of evidence, yet Nemeroff, Schatzberg, and the American Psychiatric Association vehemently deny that this was ghostwritten. (Read the APA's denial here). Rumor has it that Schatzberg is sicking his attorneys on anyone who dares to suggest what seems to be crystal clear based on the documents. But who cares, really? If it was ghostwritten, that's unethical. If it wasn't ghostwritten, it's actually worse for these academics--because the final result is such a finely crafted piece of promotion that any reputable "author" should be embarrassed and ashamed. This is truly a case of "damned if you do, damned if you don't."

You open the book, and the first thing that slaps your retina is a chapter on anxiety disorders. I’ve read a lot of psychiatry textbooks, probably over a hundred, and I can confidently report to you that I have never seen a textbook on general psychiatry (whether written for psychiatrists or PCPs) that begins with a big honking chapter on anxiety disorders. Most begin with tips on diagnosis, basic principles of psychopharmacology, mood disorders, or other topics. But they never begin with anxiety disorders.

How could this possibly matter, you might ask? Because in 1999, the book's publication date, Paxil was in the midst of a blockbuster sweet spot, buoyed particularly by FDA's 1999 approval of the drug for social anxiety disorder. Like all good drug reps, Nemeroff & Schatzberg lead with their product's strength. Thus, on page 18, we hear the rather startling statement that "social anxiety disorder is the most common anxiety disorder and the third most common psychiatric disorder in the US, preceded only by depression and alcohol dependence." That's based on a credulous acceptance of the inflated 13% prevalence figure for social anxiety that was published in 1994. This figure was also the basis of the famous "1 out 8 people have social phobia" line parroted by SmithKline Beecham in their marketing material at the time. Two pages later readers are reassured that there exists a solution to this public health catastrophe: "Currently, only one antidepressant (paroxetine) is FDA approved for the treatment of social anxiety disorder."

Does this prove blatant bias? Is it deceptive? No on both counts. It just lays the groundwork, softening the mark, as a drug rep would say. The entire first chapter is positioned front and center as a way of creating a platform for a series of boasts about Paxil's efficacy. Someone made the decision to organize the book this way, and someone had a reason to do so.

The actual deceptions begin in the chapter on antidepressants on page 77. Here's where Nemeroff and Schatzberg educate PCPs about the confusing array of antidepressants available. Then and now, if you were to ask your average psychiatrist how he or she chooses an SSRI, you would hear that they are equally effective, but that they differ based on side effect profiles. And since the late 1990s, it has been generally acknowledged that the SSRI with the most troublesome side effects is Paxil.

But not according to Nemeroff and Schatzberg's Paxil-funded textbook. Taking a break from the world of general scientific knowledge, this chapter says, essentially, that all SSRIs have some side effects, and that any differences among them are minor.

For example, both Prozac and Paxil have long been known to increase the levels of other drugs that patients may be taking. This is called "drug-drug interactions." In 1999, Paxil and Zoloft reps were sniping at one another over this issue. Zoloft reps were crowing about how "dirty" Paxil was, pointing out that Zoloft, at usual doses, caused hardly any drug drug interactions. Paxil reps, for their part, were desperately trying to downplay this.

So how do Nemeroff and Schatzberg handle this issue? They create Table 47 on page 85, entitled “Common Drug Interactions with SSRIs”. Here, there is no distinction between Paxil and Zoloft. A primary care doctor would falsely conclude that there was no reason to favor Zoloft over Paxil in patients also taking medications like propranolol or Vicodin or amitryptyline. Based on this deceptive table, they might well have favored that wonderful anti-social anxiety drug, Paxil--with potentially serious medical consequences for their patients.

Interestingly, several years later, when Nemeroff was paid by a different drug company, he had a financial incentive to play up Paxil’s drug interaction liabilities. In this CME article funded by Bristol-Myers Squibb to push their antidepressant EMSAM, here’s what Nemeroff and his co-authors had to say about SSRIs and drug interactions: "Not all antidepressants affect CYP enzymes. Antidepressants that do not substantially inhibit any CYP enzyme at their usual therapeutic doses include the SSRIs citalopram, escitalopram, and sertraline [Zoloft];… fluoxetine and paroxetine [Paxil] at 20 mg/day produce approximately a 500% increase in the AUC of CYP2D6 dependent drugs.” This article was eventually cited by ACCME as being blatantly biased in favor of EMSAM, and the company that produced it promptly went out of business.

Not only did Nemeroff and Schatzberg omit data about Paxil's drug interaction dangers, they also neglected to discuss data available in 1999 showing that Paxil caused more sexual dysfunction, more weight gain, and more sedation than other SSRIs.

To sum up, in 1999, Nemeroff and Schatzberg published a textbook called "Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care." It was funded by SmithKline Beecham with a $120,000 "unrestricted educational grant." Documents posted on the internet hint strongly that the book was ghostwritten by a PR firm hired by the drug company. And an analysis of the book's content shows that it was crafted to encourage primary care doctors to prescribe Paxil preferentially over its competitors, such as Zoloft.

This is yet another heaping of shame upon psychiatry. Rather than sending bullying lawyer letters to whistleblowers, I suggest that the authors issue the following statement: "We hereby apologize to the medical community and to the public for having published this textbook. In 1999, financial relationships with the pharmaceutical industry of this type were considered acceptable. In retrospect, by having legitimized what was essentially a promotional document for SmithKline Beecham, we realize that we did a disservice to the physicians who read the book, and who falsely assumed that the information was objective. We, in conjunction with the American Psychiatric Association, officially retract this textbook in its entirety."