Rosenberg Covers the APA Meeting

I enjoyed Chicago journalist Martha Rosenberg's take on the APA meeting in New Orleans, which you can read at Scoop Independent News. Although Rosenberg is obviously a partisan, her coverage is entertaining and brimming with telling little details.

For example, she found it ironic that after all of the damning press on Charles Nemeroff's undisclosed conflicts of interests with pharmaceutical companies (which led him to resign his chairmanship at Emory), where should he show up? In the same hallowed location where Mina Dulcan became apoplectic toward me--namely, the book-signing dias at the American Psychiatric Press.

To quote Rosenberg: "Nemeroff was signing the Textbook of Psychopharmacology which he co-edited with Schatzberg, also investigated by Congress. Schatzberg, psychiatry chairman at Stanford, consults to seven drug companies, owns stock and patents with others and is on Sanofi-Aventis' Speakers Bureau according to the meeting's Daily Bulletin."

By the way, there is an interesting back story on Dr. Schatzberg. The official meeting's program book begins with a fat disclosure section, listing all of the speakers who have financial relationships with industry. The next, far thinner section, lists speakers who have no such relationships. Inexplicably, Dr. Schatzberg's name is listed in the weight watcher's section. An anonymous tipster emailed me this glaring error, and I immediately called the press office for an explanation. The friendly staff member only had to hear me introduce myself before she interjected, "Hi Dr. Carlat. Are you calling about Dr. Schatzberg?" "Uhh, yes I am." "The correction is printed in today's meeting bulletin." Apparently several other Schatzberg-watchers beat me to the punch. Or maybe the doctor himself noted the error and corrected it?

I'm going out on a limb and saying that I imagine that the APA's beleaguered press staff is not unhappy that Dr. Schatzberg is the OUTgoing APA president. But that's just a guess.

A Hot City, an Empty Exhibit Hall, and a Stern Mina Dulcan

The annual meeting of the American Psychiatric Association was held in New Orleans this past week. The weather was hot (in the mid-90s) though the meeting was somewhat tepid and under-attended.

The exhibition hall in particular had an empty and echoey feel that I had not seen in years past. I talked to one exhibitor, my friend Dr. David Robinson, the prolific author of several books and the owner of Rapid Cycler Press, who told me that ever since the drug companies had stopped giving out free gifts, the attendance at exhibit halls was down. “In the past, they used to line up before the hall opened in the morning. No more.” This is not terribly good news for the publishers, but on the other hand publishing is undergoing unrelated and much more far-reaching changes with the advent of e-books, and the ritual of carting tons of paper to exhibit halls will eventually end.

Another attendee, a noted researcher in mood disorders, told me that he noticed fewer psychiatrists from other countries this year. Most such psychiatrists typically receive travel funding from drug companies. But this year, because of the APA's decision last March to phase out industry-funded symposia, fewer companies were willing to pay the travel expenses of our foreign colleagues. What's the connection, you might ask? In the past, companies justified these travel expenses because they knew that the sponsored psychiatrists would be attending their CME symposia, which are infomercials in support of their latest drugs. There were only two such symposia this year. So the ROI (return on investment) of funding foreign attendees is no longer robust enough to justify the marketing expense.

Nonetheless, there were still plenty of exhibitors, including mega displays by Merck to push their antipsychotic Saphris (ALL the effectiveness, plus a numb mouth and a metallic taste!), Shire for Vyvanse (proud sponsors of drug diversion for college students since the 1990s), Lilly for Cymbalta (depression is painful, depression is painful, depression is....), and several others. And they were still giving away things, but not the disposable cameras, personalized business cards, or emblazoned clocks of old. Now, the only things they can offer are "educational" items such as textbooks, and here Stephen Stahl was the superstar, doing book signings for various drug companies (you can see one of the announcements here) who have found that his faith in molecular psychopharmacology dovetails nicely with their marketing messages. The man's a great writer, I'll give him that, and he works the pharma angle with the energy and creativity of a Barnum and Bailey circus hawker. He's obviously making some serious cash from industry, but frankly, I'm a little embarrassed for him.

However, I'm the one who should really be embarrassed. Sauntering through the APA's official book publishing area, I came across Dr. Mina Dulcan, Chair of Child Psychiatry at Northwestern Medical School. She was signing copies of her various textbooks. She's a bigwig in the field, having been the editor in chief of the major journal in child psychiatry (the Journal of the American Acacemy of Child and Adolescent Psychiatry) until recently. (The photo above was apparently taken after the events outlined below. It was published in the APA's daily meeting bulletin--and yes, they spelled her name wrong).

Anyway, I went up to her to introduce myself in order to show her a copy of my new newsletter, The Carlat Child Psychiatry Report, edited by Dr. Caroline Fisher from UMass Worcester.

"Hi Dr. Dulcan," I said, "I'm Danny Carlat, nice to meet you."

She took a look at my name tag, and said, "Oh, I've heard about you."

Since her expression was somewhere between stern and outright hostile, I queried, "In a good way or a bad way?"

"In a bad way, to tell you the truth." And then she was off on a high volume rant that went something (if memory serves) like this:

"How DARE you write an article in the New York Times saying that your therapy training at Mass General was terrible, and then later having this GREAT AWAKENING that"--she made a religious hand waving gesture--"'Oh, it's important to understand my patients,' and then you write an article in order to sell your new book and your newsletter. How are you any different from the drug companies? I was outraged by your article and showed it to my colleagues. What a disservice you have done to psychiatry." And it went on from there.

Her argument was not new to me, certainly has its merits, and I am generally happy to engage in constructive debate. But this was not debate, it was simply a very angry person yelling at a colleague with dozens of other psychiatrists looking on in jaw-dropped amazement. I decided not to prolong this awkward encounter (to the relief, I'm sure, of the leaders of American Psychiatric Press who were nearby), and slunk out of the booth, passing along the way a psychiatrist who smiled at me and whispered, "I subscribe to your newsletter and love it!"

Psychiatry--truly, a House Divided.

New BBC Program: Rewriting the Psychiatrist's Bible

Several months ago, a BBC producer contacted me to ask if I'd like to be interviewed for a planned radio program examining the DSM and related topics, such as the relationship between the drug industry and the American Psychiatric Association. Being the shameless self-promoter that I am, I assented, and that program is now available on the BBC website.

Aside from listening to me ramble on about things that you've read about in this blog, you'll hear some very thought-provoking interviews of Michael First, the editor of DSM-IV, Lisa Cosgrove, the U Mass professor who published this influential article about the industry ties of members of DSM committees, Peter Tyrer, a professor at Imperial College in London who talks about the validity problems in DSM disorders, David Kupfer, chair of the DSM-V committee who makes a brief appearance, and others.

To listen to the program, click here.

Here is the BBC's description of the program:

Rewriting the Psychiatrist's Bible

Matthew Hill investigates the links between psychiatrists and the pharmaceutical industry. Should there be increased transparency over top psychiatrists' links to the industry? He looks at the influence of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), produced by the American Psychiatric Association (APA), which has been heavily criticised in the past for a lack of transparency between the panel members and pharmaceutical companies. Matthew also examines the 'Chinese menu' aspect of the DSM's diagnostic criteria and the sheer number of conditions it includes. Matthew investigates whether the APA's transparency policy goes far enough and if we are medicalising real conditions or just traits of human personality.

Broadcast on:
BBC Radio 4, 8:00pm Tuesday 4th August 2009
Duration:
40 minutes
Available until:
8:42pm Tuesday 11th August 2009

DSM-V Transparency: A Case Study

Last month, I wrote a few posts on the ongoing controversy about DSM-V, which is the next version of psychiatry's "bible," the Diagnostic and Statistical Manual. A quick recap: Dr. Allen Frances, the chair of the DSM-IV task force (who was shut out of the the DSM-V task force) wrote a scathing editorial for Psychiatric Times in which he questioned whether there has been sufficient progress in psychiatry to merit significant changes in the manual. The APA responded with a rebuttal, and so on.

Underlying these tiffs is something that must now be regarded by most APA leaders as a mistake: the early decision to require that DSM-V task force members sign a "confidentiality agreement." Drs. Regier and Kupfer maintain that this was merely a kind of "no-compete" clause to prevent task force members from writing and making money off their own versions of DSM. But Dr. Frances said the agreement was part of DSM-V’s “inexplicably closed and secretive process.”

Confidentiality agreement or not, as it turns out, there are glimpses of complete DSM-V transparency here and there. Take a look at this web page from the excellent Schizophrenia Research Forum website. Entitled "Live Discussion: Is the Risk Syndrome for Psychosis Risky Business?", this describes in detail the proposal for a new disorder called "Risk Syndrome for Psychosis." You can access the proposed criteria for the disorder, including the text discussing characteristics, associated features, differential diagnosis, etc.... So far, there are 23 comments posted, constituting a rigorous debate about the pros and cons of the proposal.

At this point, the diagnosis may or may not make it into DSM-V. It really depends on whether there is strong enough research indicating that treatment of early forms of psychosis can head off the later development of schizophrenia. My understanding is that the research is unconvincing, but I'm willing to defer to these specialists, who clearly know a lot more about psychosis than I do.

The point is not so much whether "Risk Syndrome for Psychosis" ends up winning a coveted spot in the DSM-V pantheon; rather, the point is that here is a case study of complete transparency, and it doesn't hurt one bit. In fact, it works exceedingly well, because it lets everyone in on the psychosis work group's thought process and it invites comments on a specific proposal. Where's the beef? It's here.

Unfortunately, if you go over to the DSM-V website and look at the official "Report of the DSM-V Psychotic Disorders Work Group," all you'll find is a very brief summary of some of the topics under discussion. The only mention of the Risk Syndrome for Psychosis is telegraphic: [One issue being considered is] "adding a risk syndrome section to DSM-V and including risk for conversion to psychosis as a category." There isn't even a link to Schizophrenia Research Forum website.

The same level of detail (ie., almost no detail) applies to the other work group reports as well. In their rebuttal to Frances, the APA leadership maintained that "the process for developing DSM-V has been the most open and inclusive ever.” Apparently they were referring to various presentations at conferences. If they want to be credible, I suggest they instruct the chairs of each work group at least to post links to all web pages containing specifics of proposed disorders. That would be true transparency, and it would make a lot of disgruntled psychiatrists happy.

Med Page Today Interviews Dr. Paul Appelbaum and Me on Industry Relationships

Yesterday, John Gever of Med Page Today interviewed me and Dr. Paul Appelbaum on various topics about the relationship between the pharmaceutical industry and psychiatry, which I have posted above for your viewing pleasure. Dr. Appelbaum is a former president of the APA and is the chairman of the "Ad Hoc Work Group on Relationships Between Psychiatrists and Medical Industries." He and the members of this group have drafted a report with recommendations for how we can clean up our act. While the report has not yet been formally approved by the Board of Trustees and is therefore not public, I can tell you that it contains many of the same elements as the recent Institute of Medicine report, which I described here. Appelbaum's report was discussed in the APA Assembly on Sunday and the review was frankly somewhat mixed. What will happen next is that the Board of Trustees will continue to elicit feedback from the APA membership and will eventually vote on whether to adopt some version of the current report. My prediction is that the current version will be adopted with very few changes, but that's only a prediction (I'm not a member of the Board, just the Assembly).

There have been a number of excellent symposia over the last few days on how to set the right distance between doctors and commercial interests and I'm coming away from this meeting with high optimism that we are really turning a corner in our profession.

APA Votes to Phase out Industry-Funded CME

The American Psychiatric Association has officially decided to phase out all industry-funded symposia that take place at their annual meetings. The vote occurred at the meeting of the organization's Board of Trustees last weekend.

The Board was presented with several recommendations of the "Ad Hoc Work Group on Financial Relationships between the APA and the Pharmaceutical Industry," a group which was formed by President Nada Stotland one year ago. I am one of several members of that group.

The official phrasing of the decision was: "The Board of Trustees voted to direct the Medical Director/CEO to phase out industry supported symposia (ISS)."

The timing of the phase-out is unclear.

In related business, the Board voted to "direct the Medical Director/CEO to explore the elimination of meals provided by pharmaceutical companies in conjunction with educational activities (as of 2010)." Basically, this means that even if some symposia are allowed in 2010 and in subsequent years, they may not be allowed to serve meals.

The APA is now the first national medical society to separate industry influence from continuing medical education. Let us hope that other organizations take the hint.

Eli Lilly and Physician Malpractice Education: The Outrage Continues

Eli Lilly & Co. is continuing to pay a major insurance company to provide sham education to psychiatrists about the liability risks of prescribing potentially toxic medications like Zyprexa.

The courses, entitled "GET THE FACTS: Understanding Professional Liability Risk Associated with Prescribing Medications,” are being heavily promoted to thousands of U.S. psychiatrists via mailings, and are offered both online and in the context of lavish free dinner programs. Although funded by Lilly, they are taught by PRMS, Inc. (Professional Risk Management Services), a risk management company that manages The Psychiatrists’ Program, a malpractice insurance policy tailored for psychiatrists.

The central message of these “educational” programs is that psychiatrists are unlikely to be sued for prescribing medications that may have toxic side effects. According to the course, “there are effective ways to decrease risk related to prescribing, and if a lawsuit is filed, the risk of a plaintiff prevailing is low.” While Zyprexa is never actually mentioned in the programs, it is clear that the intent of the courses is to convince psychiatrists that they are unlikely to be successfully sued by patients claiming that Zyprexa has caused obesity or diabetes.

There are numerous veiled allusions to Zyprexa in the course. In the introductory section, for example, they state that “Advancements in medicine usually add to the complexity of treatment and at the same time increase patients’ unrealistic expectations about treatment outcomes. Patients may be less likely to accept that unexpected and adverse outcomes are a part of treatment. Even in the absence of negligence, there are always risks of medical treatment that must be weighed against the benefits.” This mirrors the common theme of Eli Lilly promotional material for Zyprexa, namely, that it is more important to focus on the clinical benefits of the medication rather than the risks associated with it.

Lilly’s extraordinarily deceptive marketing tactic takes on new relevance with the unsealing two days ago of internal company documents in the State of Alaska’s suit against the drug-maker. According to Bloomberg News, an instruction sheet given to Lilly sales reps in 2002 stated that: “We believe it is essential to weaken this link to neutralize the diabetes/hyperglycemia issue. Neutralizing any concern from our customers will be essential to the future growth of Zyprexa in the marketplace.” Meanwhile, the company’s own data showed that patients taking Zyprexa had 3.5 times the rate of high blood sugar as patients taking a placebo.

PRMS’s psychiatry insurance program is the only malpractice program receiving an official endorsement from the American Psychiatric Association. While the APA neither endorses nor participates in this educational exercise, the fact that it endorses PRMS means it may have leverage in curtailing the company’s unethical activities. Psychiatrist and APA member Dr. David Port originally alerted me to these shenanigans, and we have jointly sent a letter to the APA requesting that the organization ask PRMS to cease this program immediately. I will keep you informed of any developments.

APA to Devise 5-Year Plan to Become Industry-Free

The incoming president of the American Psychiatric Association, Nada Stotland, M.D., is getting serious about the distorting effects of drug company money on the organization. She recently formed two new groups to scrutinize this issue.

The first is called the Committee on Commercial Support. I don't know any details about this yet, because I'm not on it. But the title pretty much speaks for itself.

I was, however, appointed to the "Ad Hoc Work Group on Adapting to Changes in Pharmaceutical Revenue." According the email inviting me to join, our mission is:

"The formation of an ad hoc work group of the Board [meaning the Board of Trustees] charged to work with the Medical Director to: identify the categories and amounts of monies received from the pharmaceutical and other industries producing products or services used in psychiatry by the APA and its subsidiaries; determine what direct and indirect financial consequences there would be from discontinuing each category; indicate how the APA could adapt to the attendant change in revenue; and to provide the Board with the elements of a 5 year plan to end or diminish the pharmaceutical revenue received by the APA. The ad hoc work group will report to the BOT with a report and recommendations by October 2008."

Thus far, the confirmed members include: the chairperson, Jeffrey Geller, MD, a public policy expert and professor of psychiatry at U Mass Worcester; the vice chairperson Dauda Griffin, MD, a psychiatrist in Cambridge MA; David Fassler, MD, the newly elected secretary-treasurer of the APA; Richard Harding, MD, APA president in 2001-2002; Carolyn Robinowitz, MD, the current APA president; and myself.

We haven't met yet, and I can't guarantee you that I'll be able to report much about the proceedings on this blog, because there are some confidentiality rules that I will have to respect in order to avoid getting kicked off. But I wanted to at least let everyone know about this extremely encouraging development.

Kudos to Dr. Stotland!