Sunday, February 28, 2010

WebMD's Big Lie

In order to provide quality web-based health content, you need money. The question is how you choose to make that money. WebMD, like many web sites, makes money from advertising, but it consistently goes several steps further, allowing its content to be transformed into one long stream of stealth advertising.

The incredibly successful company was just caught red-handed by Senator Chuck Grassley, who
saw a WebMD television commercial encouraging viewers to log on to the site in order to take a depression screening test. When Grassley navigated over to the test, he found that it was funded by Eli Lilly—information that was apparently omitted from the TV commercial.

What's the big deal? At first blush, this looks like business as usual. I read through the test, which appears to simply go through the DSM-4 criteria for depression, one at a time. Nor is the test actually written by Lilly. In fact, at the top of the page is the statement “This content is selected and controlled by WebMD's editorial staff and is funded by Lilly USA.” So it would appear that Lilly paid WebMD staff to encourage people to discover whether they have depression, and to seek appropriate treatment from their doctors. Yes, some of these patients might end up on Lilly’s antidepressant Cymbalta, but others would be prescribed competing antidepressants. Looked at this way, this isn’t particularly deceptive or nefarious. In fact, it might be interpreted as a public health service--enhance awareness of depression, and everybody benefits.

But of course this story isn't quite that benign. Let’s take a closer look at Web MD’s depression screening test. DSM-4 lists nine possible symptoms of depression, yet WebMD’s test lists ten. Here is WebMD’s extra item:

“I'm having frequent headaches, stomach problems, muscle pain, or back problems.



Now, nobody would insist that the nine DSM criteria are the be-all and end-all of depression. Depressed patients often experience problems that are not specifically included in DSM-4’s list. These include symptoms and behaviors like lowered sex drive, irritable mood, excessive use of drugs or alcohol, and, yes, various physical aches and pains. There are many more. So why, out of the dozens of possible depressive symptoms not listed in DSM-4, did WebMD decide to ask about one, and only one, in particular: aches and pains?

Because Lilly markets Cymbalta as the "go to" antidepressant for patients who have both depression and physical pain. This is not really a "depression screening test" at all. Instead, it is a "Cymbalta-requester" screening test.

WebMD is telling the public a big lie. The say that “
this content is selected and controlled by WebMD's editorial staff” when in fact the crucial aches and pains questions was selected by Eli Lilly’s marketing team to encourage patients to ask their doctors for Cymbalta.

The company's blatantly deceptive techniques are particularly ironic given that WebMD's CEO, Wayne Gattinela, likes to talk up "transparency" in interviews about his company. Clearly, WebMD would never allow transparency to get in the way of an Eli Lilly payday.

Tuesday, February 16, 2010

DSM: The Everlasting Gobstopper of Psychiatry

The DSM is the Everlasting Gobstopper of psychiatry, providing a seemingly endless store of material for bloggers, journalists, academics, and other commentators.

I looked through the comments on my last post and was impressed by how articulate they were. I'll spend the next few posts commenting on some of the comments. How's that for narcissistic exploitation of one's own blog?

S pointed out that “a reasonable, experienced, compassionate doctor will not be bound up by DSM diagnoses,” and accurately followed that up with “but I suspect all of us here know that there are plenty of doctors who can't see past rigid categorization or have a two-dimensional view of their patients.”

I agree. Michael First, who was the editor of DSM-IV, once told me, “We used to joke that DSM should come with a combination lock and you can only open the book if you agree to really explore what is going on in the patient’s minds.” I think of DSM is a map into the mental world. It allows us to locate a patient in a general region, but not much more than that. To truly make the diagnosis, we have to do the messy work of talking with the patient and exploring what’s going on. In fact, the term “diagnosis” is a misnomer and should probably never have been borrowed from the rest of medicine, since it implies a precision utterly lacking in psychiatry circa 2010.

Dr. Peter Huang likes the new dimensional aspects of the DSM-V, but is concerned that the new disorders being proposed "will serve as an even bigger seed that Big Pharma + the APA + the FDA will use to increase further the insanely vast quantities of psych meds that are prescribed.” This is also Dr. Allen Frances' main critique in his essay,
Opening Pandora’s Box: The 19 Worst Suggestions For DSM5. I agree that this is an inevitable consequence of elaborating the DSM, but only if we psychiatrists acquiesce. Some of these "changes" represent little more than a shuffling around of criteria from one label to another. The two risk syndromes (for psychosis and dementia) are potentially more insidious and might be exploited by drug companies for commercial gain. For this reason, I find it rather unlikely that both will make it into the final version--I predict that mild dementia (in the new vocab, "mild neurocognitive disorder") will make it through the gauntlet, but not "risk syndrome for psychosis."

Dr. Joseph Arpaia points out that DSM is mute when it comes to how the environment produces psychiatric symptoms: “The minimizing of the environmental effects means that the brain's attempts to adapt to the environment are seen as inherent brain pathology. This is as absurd as stating that an immune response to a bacterial invasion is an inherent immune pathology.”

However, the reason DSM does not mention environment is that it attempts to be “agnostic” when it comes to statements of causation. Yes, depression can be caused by many things but DSM simply runs down the list of symptoms. This speaks to the issue of how the document is used. If someone invented a DSM robot (perhaps in Freud's likeness), such a machine would, indeed, simply go through the lists and makes a bunch of diagnoses divorced from context. But thoughtful clinicians, whether psychiatrists or psychologists or social workers, don’t use the manual this way. Don't expect DSM to be more than it is, which is bare-bones descriptive psychiatry. At this point, we know too little about causation to do anything more than describe symptoms.

That's all for now--stay tuned for our next installment of "Commenting on the Commenters."

Thursday, February 11, 2010

DSM-5's Rough Draft: The Carlat Take

In a prior post, I observed that the process of hammering out the DSM-5 had degenerated into a bar room brawl. Major figures in the development of past DSM versions, such as Allen Frances (the DSM-4 chairman) and Robert Spitzer (DSM-3 chairman), had both severely criticized the DSM-V process for lack of transparency and for a headlong rush to get the thing done too quickly in order to start making the APA some money.

Looking at the just-released proposed DSM-5 criteria, I'm pleased to say that the APA leadership has apparently been listening. They've pushed the planned publication out two full years to 2013, giving everybody time to review the proposal and to do some field testing. They have made the process far more transparent by posting task force reports on the DSM-5 web site. And they have avoided trying to pretend that DSM is ready for a paradigm shift in which diagnoses are based on neurobiological criteria (here's a secret--they don't exist yet in psychiatry).

Here's a quick Carlat-tour through some of the the main proposals.

--Temper dysregulation with dysphoria (TDD). A much more accurate way of categorizing children with explosive temper tantrums so that they don't get misdiagnosed as having bipolar disorder. This is a response to the fact that the diagnosis of bipolar disorder in children has increased 8,000% over the past decade.

--Addiction and Related Disorders. No more having to deal with the confusing terms "substance abuse" vs. "substance dependence"--both will be jettisoned in favor of the catch-all term "addiction." Currently, "dependence" is supposed to be a more severe problem than "abuse" but there was no good way of distinguishing the two in real patients. When someone has a problem with drug or alcohol craving, it's an addiction, pure and simple, and DSM-5 will acknowledge this.

--Autism Spectrum Disorders. This makes a lot of sense. No longer do we have to figure out: "Is this mild autism? Or is it severe Asperger's?" Now we can describe such patients as being somewhere on the spectrum of autism and spend more time understanding them as people rather than coming up with just the right label.

--Binge Eating Disorder. Some might see this as a form of disease mongering--that is, expanding the definitions of diseases to label more and more people as mentally impaired. But in fact I see patients with BED (as it's abbreviated) in my office with some frequency. These are not just overeaters, but rather patients who compulsively binge and have lost all sense of control.

--Risk Syndrome for Psychosis. This is a bit more iffy a proposal in my opinion. The idea is that you can diagnose people who have milder symptoms of psychosis before they develop full blown schizophrenia. Then, maybe you can prevent a more severe disease by starting them on prophylactic antipsychotics. But the research is debatable. Only about 35% of patients who qualify for this "pre-psychosis" end up developing true psychosis. I doubt this will make it into the final DSM-5 as an official disorder.

There are others potential disorders to examine, but I'll look at those in future posts. We all have a few years to comment on these proposals, and I think they are offered in the spirit of healthy conversation and debate. Thumbs up to the DSM Task Force.

Wednesday, February 3, 2010

Lilly: "Execute the *%#&*! out of them"

A new paper, written by Glen Spielmans and Peter Parry and published in the journal Bioethical Inquiry, shows how various drug companies, particularly Eli Lilly and AstraZeneca, manipulated science and lied to doctors in order to sell their drugs. While this is not exactly news, the intriguing aspect of this article is that the authors reproduce e-mails and slides that are the smoking guns of deceptive sales practices. And let me tell you, these gun barrels are hot and you can still smell the gun powder.

"The data don't look good."

That's what John Tumas, an AstraZeneca publications manager, wrote in an email to a brand manager and a scientist. He was referring to an AstraZeneca-funded study showing that Haldol was superior to Seroquel (oops!). The fact that AZ officials knew about this data didn't prevent them from sending one of their hired guns to an APA meeting two months later to claim that Seroquel was "significantly superior" to Haldol.

When AZ didn't have the stomach to lie about unfavorable study results, they did the next best thing--they buried them. "Thus far," wrote Mr. Tumas in a different email, "we have buried Trials 15, 31, 56 and are now considering COSTAR."

Zyprexa and Weight Gain: "Don't introduce the issue!"

Eli Lilly knew that Zyprexa caused enormous weight gain as far back as 1995, and knew that it was worse than competing atypical antipsychotics as of, at the latest, 1999--we know this because Alan Breier (now Lilly's Chief Medical Officer) admitted to senior executives in an email that "Fact: the order of weight gain among antipsychotics is: Clozapine>olanzapine [Zyprexa]>seroquel>risperidone>traditional neuroleptics."

But in 2001 Lilly sales reps were being trained to "neutralize" physicians' concerns about weight gain by pushing what managers were calling a "comparable rates message." Most of all, reps were instructed to follow the "don't ask, don't tell" policy favored by the U.S. Army regarding a different inconvenient issue.

There are many other zingers in this comprehensive description of what the authors call "Marketing-based Medicine" as opposed to "Evidence-based Medicine." The entire paper is required reading for those interested in the realities of pharmaceutical marketing in the modern age.