Wednesday, October 21, 2009

New York Times Covers Industry Funding of CME

It is unusual for the New York Times, or any other national news organization for that matter, to focus industry-funded CME. With examples of corrupted business practice everywhere, this particular little slice of corruption is easily glossed over. But Duff Wilson, in today's NYT business section, does a good job of covering the issue, and the big paper's attention has apparently done what nobody else has been able to accomplish--convincing the ACCME to finally publish its Rogue's Gallery of MECCs found guilty of commercial bias.

The article is centered on a little gem put out by CME Outfitters called "Atypical Antipsychotics in Major Depressive Disorder: When Current Treatments Are Not Enough." Funded by AstraZeneca, it is an elaborate commercial urging psychiatrists to use more atypical antipsychotics as adjunctive treatment of major depression.

Bernard Carroll, a psychiatrist and blogger for Health Care Renewal, complained about the program (see his post
here) and while it took ACCME nine months, they eventually agreed that the program was biased in that it "lacked sufficient information about possible adverse effects of treatment with atypical antipsychotic drugs; and failed to emphasize sufficiently the efficacy of alternative treatments."

Apparently CME Outfitters has taken the program off its
website, but never fear, I've managed to get ahold of the slides and have published the pdf on Scribd here.

The interesting thing is that while this course certainly is commercially biased in favor of atypicals, it is hardly the most blatant example of commercial bias I've seen. In fact, if you go right now over to the
new activities area of CME Outfitters (called "neuroscience CME"), you'll find a entire series of "CME snacks" on the "Complex Presentations of Sleep Wake Dysfunction," each of which is a mini-commercial for Provigil and Nuvigil brought to you by Cephalon, which markets a vastly lucrative alertness drug empire.

My point being that if the Atypical Antipsychotic program is bad enough to be pulled for commercial, my conservative estimate is that at least half, probably more, of all industry funded psychiatry CME will also need the retraction treatment. The problem is, who on earth has the time to police these things? Certainly not ACCME. Dr. Carroll and I try to keep on top of the worst of the worst, but we have other things to do in order to make a living. The best and simplest solution would be to end industry funding of medical education altogether.


Anonymous said...

By God, its gotten to the point where I can hardly read an industry funded research paper without wondering what is being left out. My clinical practice has become very conservative. I don't entertain drug reps and don't accept any gifts from them (including paying for all of my own CME). I actually think my outcomes are better now because my level of confidence in the medications I am prescribing is based on many years of available data rather than a marketing campaign. The older medications still work and their predictability is higher. Not knowing the side effect profile for a medication is not the same as a medication having fewer side effects. Industry funding undermines the credibility of even valid new data.

Anonymous said...

As an experienced FDA Psych reviewer my first words of advice to any new FDA reviewer I meet are always:


As for experience and AEs one thing I realized is that if I assume that a psychiatrist sees a patient for 1 hour every 3 months then they can't have more than 500 patients in their practice.

Considering the many diagnoses and the multiple possible drugs I don't think it's very likely that a clinician would even pick up on a drug that causes a serious but typically missed and even then typically misdiagnosed toxicity that strikes 1 in 200 people or even more.

Antipsychotics kill 1 in 80 schizophrenics on them from 6 months to a year. This is from public data from at least 3 different antipsychotics and I've looked at a lot more nonpublic data than that). Plus you need to remember these are relatively young healthy adults without other medical problems.

FDA now only requires labeling to report AEs that occur in greater than 5% of individuals and twice as many as placebo.

So what about Zyprexa that caused liver problems in 1 in 8 kids on it for only 2 weeks, some are reported as increased LFTs, some as inc. transaminases, some as something else, some as something else and so on. Overall no more than 2 in any one category (2 in 80 or 2.5%). Plus they claim it's "qualitatively" similar to adults.

Over 500 years ago Parcelsus said

'The dose makes the poison'

How high a dose do you think people might push a drug in kids?

Anonymous said...

This all sickens me and is why I am looking at going back to do a pathology residency after 15 years of psychiatric practice. Psychiatry is bad for almost everyone who seeks it out. The world would be better off if it did not exist.

SteveM said...

Re: Psychiatry is bad for almost everyone who seeks it out. The world would be better off if it did not exist.

With Reptiles like Schatzberg elected by his peers to run APA, it doesn't look good...

Anonymous said...


"Psychiatry is bad for almost everyone who seeks it out. The world would be better off if it did not exist."

Are you really a psychiatrist? It's hard to believe anyone who treats the mentally ill would say the world would be better off if psychiatry didn't exist. You are free to practice any way you wish...

Or do you think letting people endlessly suffer with their hallucinations, delusions and suicidal obsessions like they used to in Bedlam is really better than treatment today?

I can't believe you're really a psychiatrist.

SteveM said...

Re: "Or do you think letting people endlessly suffer with their hallucinations, delusions and suicidal obsessions like they used to in Bedlam is really better than treatment today?

Few are advocating that. What disturbs people is the general direction of psychiatry away from a holistic treatment paradigm to mechanistic psycho-pharmacology.

Moreover, in some respects, psycho-pharmaceutical therapy is like chemo-therapy. Dirty drugs are acknowledged to be required to treat very severe illness. It's the expansion of the therapeutic indication for those drugs to less severe mood disturbances and episodic life events with the concomitant abandonment of non-drug therapies that rub observers the wrong way. (Rightfully I believe.)

Toss in the rancid contamination of Big Pharma and you have a professional mess on your hands.

Anonymous said...

The people you describe suffering in "Bedlam" are not the majority of people taking $20Billion per year of psychotropic drugs. I can't believe I am a psychiatrist either but what I am is an honest person who is not so self absorbed about what they do that they are afraid to confront failure and that medicine and psychiatry have a long track record of harming people in the name of TX. Cold water baths, frontal lobotomy, isolation chairs are all part of psychiatry and its past. We have come forward for some true, but backwards for most. I stand by my statement. If we are so great why does the WHO report outcomes for psychosis long term are better in third world countries? There is 400% more mental health TX than in 1950 and disability rates have increased almost 7 fold. Great batting average huh? I wish psychiatry helped most people. No one wishes that more than the skeptic/psychiatrist. This does not make it so.