I am writing this because I feel furious. Because I’ve had to sit through another dreadful presentation by a pharmaceutical representative telling half-truths and lies. No one but me questioned these. If you show a slide in which a depot injection reduces relapses, compared to an oral preparation, then know this – dopamine super-sensitivity caused by coming off the oral medication is real. It probably causes the sudden relapse, rather than any intrinsic disease. If this is used this to justify some economic analysis that a new – very expensive – injectable antipsychotic will save one’s healthcare organization money by reducing relapses and therefore expensive re-hospitalizations then, by the previous point, you’ve created a false economy.
And where in the analysis is the cost of all the excess morbidity and mortality caused by these drugs? Diabetes, a common side effect of most atypicals, for example, is estimated to cost the National Health Service in Britain £25,000 per minute. To me, a more truthful reading of this economic analysis is that depot injectables ensure the company a steadier income.
If one slide includes pictures of brain scans of people who don’t take their medication, progressively atrophying, until you are left with something looking suspiciously like Alzheimer’s disease, then I’m afraid it is lying. I wrote to the rep. asking for some source documents for these claims. He sent me the slide. The images are drawings not photographs. They depict four pictures of the two third ventricles in a sagittal plane (i.e. from back to front) which on the first are weirdly, abnormally small, like a pea; and by the fourth, have grown, comparatively, to the size of orange segments. Like all advertising they are fictions that try to make an emotive appeal, rather than muddy the water with facts.
The references at the bottom of the slide, are to two papers by Lieberman J. A. (2001 and 2006). The flaws in Lieberman’s studies have been discussed by Joanna Moncrieff here http://joannamoncrieff.com/2013/12/13/antipsychotics-and-brain-shrinkage-an-update/. Lieberman’s studies have now been superseded by Nancy Andearson’s (2011, 2013) studies which, to my mind, conclusively show it is the drugs which cause the atrophy and not any disease process. There are other recent studies to back this up. Furthermore, by their own admission, in a systematic review for the BJPscyh (2006) Steen et al (Lieberman J.A was a joint author) state “average volumetric changes are close to the limit of detection by MRI methods”, meaning that you wouldn’t see it with a naked eye, let alone capture it on some crude drawing. I wonder if Jeffery Lieberman takes as much time and energy castigating the drug industry for misrepresenting his data, as he does about attacking anyone being critical of the heroic profession of psychiatry.
I started training as a psychiatrist around the time Prozac first came onto the market. I remember the advertising well. At least in Britain, the leaflets, put in front of me by the pharmaceutical rep., depicted a climber, a man, standing on top of tall, priapic rock. The words read: Leadership is not given, it is earned. I used to argue with the rep. saying, of course, in the case of Prozac, it has been given: You are all over the press; there are books written about Prozac, You have entered the public imagination; Prozac is a household name. I had little idea back then of how Lilly had manipulated and influenced all the above. There was no internet back then.
Thanks to the internet, and to people like Peter Gøtzsche, David Healy and Ben Goldacre, we now know what earning leadership actually means; John Virapen, the Lilly executive turned whistleblower, had bribed a doctor, acting as an independent expert for the Swedish drug agency, to get Prozac approved in Sweden, thereby, opening the gates to the rest of the world (Gøtzsche 2013). SSRIS have also, more recently, been shown to be no more effective than placebo (Kirsch et al 2008). The tall, slender rock begins to look suspiciously like a middle finger, stuck up at the world, as if to say, we can do what the hell we want, including, as it turns out, killing a few people along the way (Healy 2012).
Throughout my training, the pharmaceutical industry were a constant presence. This included visits from pharmaceutical representatives, sponsored academic meetings, lunches of supermarket sandwiches brought to our team base, being taken out to dinner in the evening with other doctors and, even, once, a weekend conference in Barcelona. Sometimes the drug was barely mentioned. I confess to not giving it a second thought. How could this influence me? I thought. Besides, nearly all my fellow trainees went along with this. It was part of the culture of my training.
I became an NHS consultant around the time new rules for engagement between the pharmaceutical industry and clinicians came into play. Despite this, I can now look back and see, just how hard they tried to hit on me: Increasing the visits; invites to academic meetings; invites for training opportunities to become a better public speaker; and e-mails asking if I knew who the key opinion leaders in my area were. I confess to feeling a little insecure about not knowing who they were, as if it was important. Now I know it isn’t. In fact, the phrase ‘key opinion leader’ should probably come with a health warning.
I have previously written about an experience of coming to my senses, regarding the state of psychiatry, after reading a Peter Breggin book. In the wake of that experience, having read widely and thought much, I am increasingly aware of the inherent problems in the current system, in which the pharmaceutical industry and economics are driving forces.
These days I notice the heavy presence of the pharmaceutical industry at nearly every academic-focused doctors’ meeting, peddling their potions with a cheesy smile and a plate of sandwiches. At the biannual Finnish psychiatry meeting, a whole floor is given over to a pharmaceutical trade fair. Each company offering a bowl of free sweets to the circulating psychiatrists, who, to my mind are like infantilized, modern day Hansel and Gretels. It’s not a bad analogy. Most of my colleagues are either, in denial, or blissfully unaware, of the influence this cozy relationship has on the way they practice.
Unless I am to be an island unto myself, I cannot avoid the pharmaceutical industry altogether. To remain connected and keep up with Continuing Professional Development (CPD), I have to attend some meetings. I have learned to buy my own coffee and refuse any promotional literature, or the ubiquitous office stationary on offer. I realize that, if accepted, I promote their wares through a process of subtle product placement. Likewise, when I moved to my new office about a year ago I cleansed it of all drug logos including the patient information leaflets, kindly sponsored by the pharmaceutical industry. Theirs’, I feel, is a very self-promotional, one-dimensional discourse of mental illness and disordered neurotransmitters, surrendering easily to the beneficial effects of medication.
At first, in meetings, I didn’t ask any questions or make comments, more due to self-consciousness about my terrible Finnish. But I took note of the material being presented, the mode of presentation, the slickness of delivery. I remember a video being shown of a long-acting depot antipsychotic molecule dissolving like a slow-motion, exploding death star. It seemed high on gimmickry but curiously devoid of science.
In another presentation a line graph showed the efficacy of low-dose quetiepine (in the guise of an antidepressant adjunct) verses placebo. What seemed remarkable is how the shape of the graph for both drug and placebo were similar, but for quetiepine the response was a couple of points ‘better’ than the placebo on a standard measure like the HAMDS. Fundamental questions — such as; how significant is this clinically? Or; aren’t we witnessing a clear example of exaggerated placebo response? Or even; do you have any data about what happened beyond the incredibly short study time? — Didn’t get asked. To any doctors out there unconvinced by what I am saying, a modicum of critical reading can help make sense of some this stuff.
These days, with a little more fluency in Finnish, I ask the questions. I frequently ask if they have any data on how easy is it to stop taking these drugs, which leads to flat denial or some fuddled nonsense. I sometimes do a quick search with my smart phone, for further information on the drug in question. In a presentation about injectable paliperidone, I found out that at least 30 people had died in Japan 1 month after being given the drug. The pharmaceutical rep’s face looked not unlike Snow-white’s step-mother’s face on finding her nemesis still alive when I asked her to comment on this.
Psychiatry and the pharmaceutical industry are deeply entwined. As Joanna Moncrieff (2013) would have it, the history of psychopharmacology, is the history of modern psychiatry. The profession has been lead down what Moncrieff argues is a blind alley of self-deception and denial. On the one hand, the disease model is readily exploited by the drug industry to further their economic interests; on the other, psychiatry has so embraced this model that psychological, social and alternative interventions are seen as secondary or adjunctive to the medications. Whereas, I am sure many here would agree that the best we can expect of medication is providing some temporary symptom relief.
Worryingly, challenging this hubris can sometimes have disastrous consequences. David Healy has talked about the persecution of heretics in his blog-posts on MIA. In Finland last summer a psychologist, Aku Kopakkala, lost his job for appearing on a current affairs television program about SSRIs. In the program, Kopakkala is very measured in the way he discusses the possible negative effects of SSRIs, for example saying that they may lead to chronicity of depression and are notoriously difficult to stop. He questions the wisdom of their widespread use in Finnish society.
His employer, a private health care organization called Mehiläinen, stated the reason for his dismissal was that the position of his employment had been stated in the program and that Mehiläinen’s employees had been instructed not to publicly criticize the national treatment guidelines for depression.
What this incident demonstrated about the state of public debate and freedom of speech in Finland is somewhat concerning. It seems inconceivable that anyone should lose their job for questioning the use of SSRIs and backing up his arguments with well-validated science. But would it surprise you if I told you, that the Vice President of working life services at Mehiläinen had previously been managing director at Pfizer Finland? From the side lines it looks suspiciously like an attempt to silence a critical voice rather than a fair dismissal.
Moreover, Käypähoito, who publish the national care guidelines, state on their web page: That the guidelines are meant to be objective and based on scientific research evidence; that the body of scientific evidence increases daily; that treatment practices should be evaluated continually in light of the latest scientific knowledge; and the goal of Käypähoito is to encourage a critical and constructive debate about treatment guidelines. Ideally, care guidelines exist to protect the public, which is why openness to scrutiny, as well as impartiality (lack of conflicts of interest), are important values to try and uphold.
Following this incident there was a public outcry. A support Aku Koakkala, campaign was started on facebook, which had grown to 10,000 likes within a few weeks. People started talking more about the role of medication in the treatment of depression. People were able to openly discuss, sometimes for the first time in a public forum, their horror stories of SSRIs. Others talked about how they had been helped by medication. There was openness and debate. These are the signs of a healthy state.
Subsequently, there have been meetings with peers and survivors who are keen to set up medication reduction groups. Aku Kopakkala has been central in helping to steer these groups forward. He’s been busy writing a blog, as well as starting to write a book about his experiences. He is also standing as the Green candidate in the Helsinki area, for parliamentary elections this year. One of the central themes of his campaign is addressing the over-medicalization of Finnish life, especially within mental health.
One of the strangest responses to all of this came from within psychiatry. Two prominent psychiatrists wrote articles, one in a newspaper and another in a medical journal, suggesting that only medical professionals should be able to critically appraise the medication; certainly not a psychologist. One even wrote that scientific arguments should not be presented at all in public.
To me this indicates a tenuous grip on what post-modernity is all about, as well as violating a basic rule of civil discourse; arguments should never be ad hominem — i.e; questioning the credentials of the person discussing the science — but rather ad rem, i.e; addressing the data, evidence, and arguments being presented. Moreover, in my experience, psychologists generally have better training in research methodology than doctors do. And, of course, anyone should be able to appraise medication, especially the patients, as they embody – literally – the experience of the drugs’ effects.
Finally, to tie it in with how I started, doctors are badly placed to appraise the science around medications. They are the very group to which, drugs are marketed. They are the ones who read the ghost-written journal articles. It is their continuing medical education that is largely funded by pharmaceutical companies. It is they who, in the interests of overcoming their cognitive dissonance, overlook the myriad conflicts of interest they are confronted with in daily clinical life.
Most ridiculously, if you can’t bear a psychologist talking about medication, why do you entertain and put up with pharmaceutical representatives on a regular basis? Many of them don’t even have a science degree, let alone clinical experience. Why is our profession so beholden to the drug industry? Do we just follow the money? Or are there more noble values that we should be manifesting? I certainly think so.
* * * * *
Andreasen, N.C, et al. Progressive Brain Change in Schizophrenia: a Prospective Longitudinal Study of First Episode Schizophrenia. Biol. Psychiatry 2001 Oct 1;70 (7): 672-9.
Andreasen, N.C, et al. Relapse Duration, Treatment Intensity and Brain Tissue Loss in Schizophrenia, a Longitudinal MRI Study. Am. J. Psychiatry 2013 Jun 1;170(6): 609-15
Gøtzsche, P. Deadly Medicine and Organised Crime: How Big Pharma has Corrupted Health Care. 2013 Radcliffe Publishing, London & New York.
Healy, D. Pharmageddon, University of California Press, 2013.
Kirsch, I. et al. Initial Severity and Antidepressant Benefits: a Meta-analysis of Data Submitted to the Food and Drug Administration. 2008, PLoS Med 5: e45–e45.
Lieberman J. A, et al. Longitudinal Study of Brain Morphology in First Episode Schizophrenia. Biological Psychiatry, 2001, 49, 487-499.
Moncrieff J. The Myth of Chemical Cure. Palgrave McMillan, 2013.
Steen R. G, et al. Systematic Review and Meta-analysis of Magnetic Resonance Imaging Studies. British Journal of Psychiatry (2006), 1 8 8 , 510 -518
Jeremy Wallace, MDThe Recovering Psychiatrist: I am a British trained psychiatrist, working in the public sector in Finland. My primary workplace is within a psychosis rehabilitation clinic. I have become increasingly critical about the way psychiatry is practiced and taught globally. My special interests are in psychosis care, cultural psychiatry and medical education.