Humanist Perspectives: issue 153: The Buying of the Medical Profession

The Buying of the Medical Profession
by Alan Cassels

illustrations in this article by Charlotte Campbell

illustrations in this article by Charlotte Campbell

“The education of physicians by the pharmaceutical industry is the single most effective adult education program in the history of the world.”
—Dr Richard Hudson, Victoria, BC

The aroma of fresh baking spills out of Michael Oldani’s car as the door swings open and he jumps out to retrieve a large box from the trunk of his blue Oldsmobile. He lifts out a box of drug samples and stacks on top two boxes of donuts, festooned with stickers bearing the name of the popular antidepressant Zoloft. As one of an 11,000 strong army of ‘detailers’ working in the USA for industry giant Pfizer, Michael greets his morning bearing a beguiling gift — donuts.

The donuts are good ice breakers — a way to get a smile from Joyce, the receptionist, when he walks through the door of the clinic, and maybe the key to snagging a few minutes of the doctor’s time. Because he knows Joyce likes apple fritters, those gooey bits of dough and apple may be what gets him an unscheduled appointment with one of the doctors — even if it is for a few seconds.

That’s all it takes, just a few seconds.

Today he’s not so lucky — the docs are too busy and already running behind — so he can’t squeeze in any ‘face time’ with a prescriber. With military efficiency he quickly refills the clinic’s sample cupboard, putting his products front and centre so they’ll be the first thing the docs see when opening the cupboard. On his way out he stops to chat with Joyce.

A businesslike yet charming manner can be a detailer’s main asset, yet for Michael his jet black hair and dark Italian good looks may also help open a few doors. Whether it is his charm or his fritters, he walks away today having gathered a few juicy bits of intelligence from Joyce. He found out which anti-depressant the doctors in the clinic seem to be favouring lately (Prozac). And why they aren’t using his antibiotic (too expensive and hard to dose). Not a bad return for the price of a box of donuts.

“Now is that why they call us ‘detailers?’” he muses as he writes down these details in his scheduler. His electronic scheduler contains a database of extraordinarily personal detail. Within it are the likes, dislikes and habits of specific physicians in his sales area, even down to such minutiae as the birthdays of the doctors’ kids and the kind of wine their spouses prefer — and of course what drugs they tend to prescribe.

Knowing what motivates individual physicians and which products they tend to favour gives the detailer incredible power in honing a hallway sales pitch: “Oh, Dr Jones, did you know your colleagues are seeing a lot of agitation in their Prozac users? Is that something you’d like to avoid in your depressed patients?” Michael knows that using and exploiting the side effects of a competitor can steer physicians in the desired direction. “Won’t you try your next patient on Zoloft. Just to see how it works?”

The world of drug and disease marketing revolves largely around the verbal exchange of information, caressed by the giving of gifts. Drug marketers have known for decades that the dominant weapon in the arsenal of persuasion is gifting — the donuts, free samples, pens and free meals bestowed on physicians by drug reps thousands of times a day around the world. This activity is intensely interpersonal, largely hidden from public view, and highly effective. In fact, people like Michael Oldani would say that these gift-greased exchanges lie at the heart of what constitutes a physician’s ongoing education about prescription drugs — and about illness.

Many people might say, “What’s the problem? My physician can see through the marketing spiels.” Yet the data says something very different. In 1998 Toronto drug policy researcher Joel Lexchin reviewed the literature on detailing by pharmaceutical industry representatives and found a very strong link between inappropriate prescribing and contact with drug reps. In fact, Lexchin found that the greater the frequency that prescribers saw industry detailers, the more prone they were to use pharmacotherapy versus non-drug therapy, the more often they favoured a ‘commercial’ view of the utility of a product versus the view promoted in the scientific literature and the more likely they were to use more expensive medications when equally effective but less costly ones were available.

The evidence proving the success of drug rep-provided ‘education’ is everywhere. The chemical cures for mental illness is a market of gargantuan size. The drugs provided for various forms of depression, particularly Prozac, Paxil and Zoloft (selective serotonin reuptake inhibitors or SSRIS) or Effexor (a serotonin and norepinephrine reuptake inhibitors) make up a market worth $14.3 billion in 2002. In fact the global antidepressant market has grown 50% since 1994, mainly due to rising sales of SSRIS. And there is no end in sight as the market continues to expand, expecting to reach $18.3 billion by 2008.

Some argue that the antidepressant drug market’s phenomenal growth is because we simply have more depressed people. Since Lilly’s Prozac was approved in the United States in 1988, the number of cases of depression has nearly doubled from 14 million to 25 million in 2001. Some say the key to this remarkable rise in numbers of depressed people is better diagnosis of people undergoing mental distress. Others blame our increasingly frenetic, stressful lifestyle and lack of social cohesion. Others say the newer SSRIS are just more effective than older antidepressants, so they get used more.

All of these may be factors to some degree, but no one can argue that a major factor in getting people to think about depression in the ‘right way’ — as a chemical imbalance — was driven by the marketing imperatives of all the major makers of antidepressants. In one sense this is remarkable when you consider that there is scant scientific evidence that such a chemical imbalance actually exists in depressed people. In fact, those who have seen secret company documents uncovered in SSRI litigation go further, saying the chemical-imbalance explanation for depression is “little more than a clever advertising gimmick which, through marketing research, has been proven to be an effective means of getting consumers to reach for a bottle of Prozac, or Zoloft, or Paxil.”

Regardless of how you view the promotional tactics of drug companies, of course, serious clinical depression is undeniably a major health problem with sometimes devastating consequences. And there are some people who respond to SSRIS — some who even claim miraculous improvements.

However, against the drug industry’s marketing campaigns which push the more lucrative chemical views of depression, alternative views of both illness and treatment get short shrift. And with the daily, constant parade of drug reps, the chemical views of illness are shaped and reinforced where nobody sees them — behind the closed doors, or in hallways of clinics in the artfully choreographed exchanges happening thousands of places per day between drug rep and physician. With a drug rep for every four doctors in the US, and on average at least one visit per day per doctor, Joyce is likely to see a parade of reps. How can we be surprised that the dominant paradigm of mental health care has been largely reduced to the tweaking of neurotransmitters and serotonin levels with patented drugs.

Over half the drug marketer’s budget goes to detailers and free drug samples (over $8 billion per year in the US). The drug company’s ubiquitous free sample — which some commentators have likened to the shady world of the schoolyard crack dealer (“Here kid, the first one’s free…”) are a remarkably effective way to get people — physicians and patients — hooked on new products. In fact the free sample is a brilliant weapon in the armamentarium of influence.

The cartons of free drug samples lugged around the USA by more than 60,000 detailers like Michael Oldani represent the promise not just of a gift of new products — but of new knowledge. They are effective because they tap into the physician’s primal motivations — wanting to appear on top of ‘new’ advances in medicines and keeping patients happy with samples that show how much they care. But what those free samples also do is enforce, promote and reinforce the dominant view of disease which a drug is designed to treat — in this case, the ‘neurotransmitter model’ of mental health.

As the world’s biggest drug companies battle to grow markets for their new anti-depressants, the field of psychiatry is where key allies and ‘Key Opinion Leaders’ (known as KOLS in the marketing world) are found who can help ‘educate’ fellow doctors about both the drugs and the diseases. These KOLS are often just ordinary members of the medical community who can make easy money by giving suitable lunchtime talks to their colleagues.

Unfortunately few of those Key Opinion Leaders come with unbiased opinions. In fact when Dr Marcia Angell, the former New England Journal of Medicine editor wrote her now famous article “Is Academic Medicine for Sale?” she singled out psychiatrists as the most powerful example of a much wider problem. She expressed alarm that in searching for potential contributors for articles on depression, her journal could only find “very few” senior psychiatrists without financial ties to the pharmaceutical companies who make anti-depressants.

A convention of psychiatrists gathering for a scientific meeting may be the ideal place to see where new definitions of mental illness are shaped and where opinion leaders come to hear what’s the newest new thing. Amid a swirl of sound, colour and movement, the cavernous exhibition area at the American Psychiatric Association (APA) 2004 conference in New York City is electric. More than 20,000 visiting health professionals and physicians from all over the world attend this annual scientific conference.

This year it’s entitled: “Psychotherapy and Psychopharmacology: dissolving the mind-brain barrier.” In the exhibition halls thousands of doctors are enthusiastically enjoying the delights of the drug company displays, gawking at the soaring high tech screens promoting the latest medications, playing games where they can win prizes or just chatting with the (usually attractive) salespeople staffing the booths.

It takes a lot of money to get 20,000 health professionals round the world to come to a meeting, and most of the APA annual conference is underwritten by the drug industry. A 10 ft by 10 ft square in the exhibit hall goes for $2,400. Scientific sessions are for sale at around $50,000 each. This is where capitalism and health care meet.

At Eli Lilly’s ‘Depression stand,’ yellow, red, purple lights flash the words “Where does it hurt?” There are no obvious drug names. Why advertise without mentioning a specific product? Because Lilly is advertising a disease, not a drug.

The “Where does it hurt?” sign flashes alternately with “What four little words could give your patient a better chance to achieve remission?”

Lilly’s new drug Cymbalta, a serotonin and norepinephrine reuptake inhibitor whose only rival so far is Effexor, has been proven in a recent clinical trial to show some efficacy in treating the physical symptoms (e.g., fatigue, back pain and aches) that often go with depression. In a crowded antidepressant market your drug has to do more than treat depression — it’s gotta do something else. But what? Associated symptoms, that’s what.

Lilly has spent more than a year prior to this conference selling the ‘hurt’ to physicians in journals such as the American Family Physician with the ad asking “What did 69% of patients diagnosed with Depression say? I hurt.” An earlier two-pager talking about depression and also seeding the ground for Cymbalta shows a bicycle wheel with the slogan: “We’re not reinventing it. We’re just taking a closer look.”

What is happening in the APA exhibit hall, however, is exactly that: reinvention. Drug companies are reinventing depression, by promoting niches which drugs in the pipeline may someday fit, drugs that aren’t even on the market yet. And they are taking existing drugs and colonizing whole new areas of treatment. This drug is now good for agitation. This one works well for pain. This one is for anxiety or tiredness.

Eli is looking to Cymbalta to be their bedrock product in the depression market and some analysts are already calling it the “next blockbuster antidepressant” No doubt its alleged dual action on emotional hurt and physical pain is the key marketing factor. There’s no better way to get Cymbalta’s sales curve climbing early than pounding that message into the physicians’ heads — long before the drug is approved.

By the time it has reached this stage at an APA conference, the drug has already passed the stage where it needed to impress investors; now it needs to impress prescribers. It’s important that the new drug be launched properly, especially to impress those who will prescribe them and those thought leaders who will encourage other doctors to prescribe it.

Meetings like the annual APA fill a crucial marketing role — part of a ‘pre-launch awareness campaign.’ As Dr David Healy notes in his latest book “Let them Eat Prozac,” the market development for a drug doesn’t just involve scientists but depends on public relations and communications companies. The goal is to make the new drug have impact and ‘brand presence’ in the mind of prescribers.

David Healy is one of a few high profile physicians who are critical of the way pharmaceutical companies have shaped physician behaviour. In 1998, in a high profile resignation from the APA Dr Loren Mosher called the American Psychiatric Association a “drug company patsy” and added that “psychiatry has been almost completely bought out by the drug companies.”

The merchants of the chemical definition of mental illness rely on a key aspect in the practice of medicine: the power of expert opinion. That’s why you won’t find many David Healys or Loren Moshers speaking at an APA conference where new depression niches for drugs like Cymbalta are being created and promoted. In fact talks on the benefits of older, cheaper medications, or the papers which show SSRIS and their links to increased risks of suicide in children, or papers promoting the benefits of cognitive behavioural therapy or talk therapy don’t actually seem to get much space on such a drug-heavy menu.

Even if salespeople are going overboard on the marketing of drugs, and there are problems with physicians being trained by pharmaceutical-backed spokespeople, isn’t there also a problem if people with mental illness are left undertreated? And aren’t physicians just responding to the hordes of patients showing up at their door, tired, in pain, and ‘depressed?’

The fact is, no one really knows what the prevalence of serious depression is. And in the case of undertreatment, going straight for the chemical solution can be seen as a problematic and reductionist solution.

No one could argue that people suffering acute cases of depression or mania shouldn’t have the best treatment available. But how many people are out there who fit this description? It is a reverberating refrain in the selling of disease that there are huge (sometimes grossly inflated) estimates of how many people are suffering from the disease and rather few who are being treated. This is the ‘gap’ which propels the marketing of the disease by public and private agencies.

Promoters of the ‘undertreatment’ paradigm are found even among those without drugs to sell. The World Health Organization cites statistics than say 121 million people worldwide are affected by depression. They project that mental disorders will increase from nearly 12% of the all diseases worldwide to almost 15% by the year 2020. The WHO uses the term ‘treatment gap’ and point out that fewer than 25% of those affected have access to effective treatments. Other groups such as the National Institute of Mental Health say that one in five adults in the USA, or 22% of USA adults, suffer from a diagnosable mental disorder in a given year.

What is lost in those numbers, however, is that they very much depend on the diagnostic criteria used by researchers. In Australia Professor Ian Hickie led a major campaign which claimed that 30% of people who walked into GPS’ offices were sick with undiagnosed mental illness. As a paid consultant to drug maker Bristol Myers Squibb, Hickie was using and promoting the use of an instrument to diagnose depression — one of those classic screening tools that seems to catch nearly everyone because the symptoms are so common. A few years later when academic researchers rigorously evaluated Hickie’s instrument, they found it totally inadequate, and were disturbed by the huge numbers of false positives — people who ended up with a label for depression who weren’t in fact depressed.

Every October National Depression Screening Day rolls across campuses, hospitals and schools all over North America, urging the general populace to ask ourselves “Are you tired? Sad? Anxious? Stressed?” In British Columbia in 2003 a one day conference entitled “Untreated Depression and Anxiety Disorders in the Workplace” organized by the Canadian Mental Health Association, was sponsored by the provincial health services, a few banks and credit unions, and Wyeth, Glaxo, Pfizer, Novartis — all drug companies that make antidepressants.

This year they’ve captured the attention of the media by having a very high profile keynote speaker, the Premier of the province, Gordon Campbell. What better way to focus the attention of the media and the masses than to use the magnet of a high profile politician? His personal story is tragic — his father, an assistant dean of medicine at the University of British Columbia, suffered from alcoholism, was fired and then committed suicide in 1961. Yet this kind of story is a golden opportunity to raise the kind of media-piercing awareness the sponsors want for their event.

Using high profile politicians in the selling of sickness is not new, and some might defend the practice saying raising awareness is vital to ensuring people get the help they need. In the case of Premier Campbell his personal story is used in neither a crass nor distasteful manner, yet it is disturbing how easily such a story can legitimize and promote the benefits of depression ‘screening’ and treatment. What a coup it is to the drug companies who — providing almost the only available treatments — can simply sit back and allow very public figures with stories to tell do their marketing for them.

Public facilities are being harnessed to the cause. The BC Ministry of Health sponsors the annual Depression Screening and Education Day as part of National Depression Month. Among the event’s ‘Gold Sponsors’ is Wyeth, who makes a leading antidepressant, Effexor. This day is designed to cast the net wide, and what better place to stage the actual screening than in the main building housing employees of BCS largest government Ministry? Given recent government cutbacks and downsizing, there is no doubt a higher-than-normal level of angst in government. Hundreds pour in to get screened.

It’s not just public health facilities that Wyeth’s marketing has invaded. Effexor is a relatively new treatment for depression and in the same SRNI class as Lilly’s forthcoming Cymbalta, and its maker has been particularly interested in targeting the 15 million American college students. Wyeth funds a series of special events on campuses involving MTV stars like Cara Kahn (who takes Effexor). “Depression in College: Real World, Real Life, Real Issues” is held in order to raise awareness about depression and the drugs to treat it. Featuring free screenings for depression and celebrity speakers, be they Premier Campbell or Cara Kahn, is all about getting impact in the community.

But critics say that such depression screening is only giving a platform to the views of those who basically have something to sell.

What’s wrong with screening? Maybe some people will be helped by being screened for depression. But critics say that such depression screening is only giving a platform to the views of those who basically have something to sell. They say that public health agencies are being duped when they sponsor and promote screening for normal mental distress, and that they are becoming unwitting medicalizers of depression.

Dr Iona Heath, a general practitioner in London, England maintains that the whole screening paradigm has never been evaluated — and there is the likelihood that pegging someone as in need of medical help may unnecessarily drag them into the maw of the medical system. While she says it’s important for doctors to be diagnosing and treating genuine mental illness, she has concerns that too many people with ordinary life experiences are being offered a label and a drug — including those who have lost a loved one, or face the prospect of job loss, or live in a damp cold home, or experience domestic violence. She writes in the British Medical Journal that the questionnaires used by medical researchers to “diagnose” depression are so broad they may wrongly label people as sick far too often.

Heath takes the time to listen to her patients who, she maintains, largely reject the ‘culture of reductionism’ which reduces their complaints to a mere problem with neurotransmitters. She sees the doctor-patient relationship in terms that don’t fit within the instant ‘pill-for-every-ill’ model, where patients are characterized as ‘broken’ and the physician is there to ‘fix’ them. She sees medical care more as a dialectic, a meeting of two experts: the doctor, an expert on disease, and the patient, the expert on the patient’s own aspirations. The goal is to come to a mutual agreement on the extent to which patients want to medicalize their lives.

She also proposes treatments from a larger bundle of solutions — like prescribing exercise which she says is ‘evidence-based’ and shows benefit but is not heavily promoted in the same way as the biochemical approaches are. She also gets people to write things down, to tell stories and to take dancing classes — reverting to the traditional human solution of sublimation, the art of ‘distracting yourself from the imminence of death and suffering.’

She is not alone in promoting the non-medication approaches to treating human distress.

Some researchers might agree that perhaps screening is not such a bad thing, especially if there are large numbers of people who may be undertreated for mental illness. But they question whether antidepressant drugs are the best way to treat those people. Despite the enormous popularity for SSRI treatments for ‘just about everything’, David Antonuccio, a clinical psychologist and professor in the Department of Psychiatry at the University of Nevada, says point blank: “the scientific data don’t support that popularity. From my perspective, there are alternatives that are just as effective and even have some advantages in terms of preventing relapses.”

After nearly 20 years of such research, Antonuccio is among the world’s experts on comparative efficacy studies, those studies that compare drug to non-drug treatments in the treatment of depression. In a 1994 article he published a study that found non-drug treatments such as CBT, talk therapy, even exercise, to be as effective in the short run and possibly more effective in the long run than drugs. What happened next caught him off guard. “We got contacted by every media outlet you can imagine — CNN, USA Today. People from newspapers and TV from all over the world were calling us. And we were thinking: “What the hell is going on? All we were saying is therapy seems to be as good or effective as the drugs in the short run, and appears to be better in the long run.”

He maintains that there is no new science to dispute those initial findings. In fact he and his colleagues have been publishing variations of the same paper for the last decade. What he says is most disheartening is that this research can’t seem to pierce the all-pervasive worldwide view of mental illness as chemically caused and treated. “Look, I was watching Good Morning America this morning and they told me ‘your weather report is brought to you by Paxil’.”

Stephen Leacock, who defined advertising as “the science of arresting the human intelligence long enough to get money from it.”

This may all bring to mind the words of Canadian humorist Stephen Leacock, who defined advertising as “the science of arresting the human intelligence long enough to get money from it.”

The culture of antidepressant use has been beaten into our collective consciousness. What doesn’t seem to get much airplay, however, around the treatment of depression with drugs, are the adverse effects associated with those drugs. A growing chorus of people charges that there are some serious downsides to the entanglement of pharmaceutical manufacturers who are defining diseases, and physicians who are writing prescriptions.

In early 2005, amid dramatic and emotional public hearings at the United States Food & Drug Administration, Karen Barth Menzies, a Los Angeles attorney, testified about the concerns relating to SSRI use in children. She cited evidence of unpublished company trials which failed to show any benefit for several of the new pills. She notes that “the clinical researchers who did these trials on kids and the drug companies themselves, confirmed that there are multiple events of suicidality caused by the drug.”

Several months after this testimony, the Attorney General of New York State launched a lawsuit against GSK, alleging that the company fraudulently withheld safety data on Paxil. He noted that “by concealing critically important scientific studies on Paxil, GSKh impaired doctors’ ability to make the appropriate prescribing decision for their patients and may have jeopardized their health and safety.”

With thousands of drug reps working the clinics, hospitals and conferences around the world, and drug-funded Key Opinion Leaders working the hotel meeting rooms around the world, how can public health compete? How can we reclaim medicine from the marketplace?

Several years ago, Bob Goodman, a New York Internist started “No-free-Lunch,” featuring a website dedicated to ways of escaping the adverse effects of influence practitioners. A group of physicians in Australia led by Dr Peter Mansfield also runs a website called www.HealthySkepticism.org, dedicated to identifying sources of commercial bias, coercion and influence on drug prescribing, and exposing the problems with ‘market-based’ definitions of disease and treatment. Both Goodman and Mansfield are examples of those who may say “prescribing under the influence of marketing is like driving under the influence of alcohol.”

Some say we are getting the medicine we are asking for. The antidepressant fits the single-pill solution that many of us expect, yet when the definitions of disease itself are being sold and where the dangers inherent in using those pills are downplayed, how many physicians really have what they need at their fingertips to help their patients get through particularly tough times?

Meanwhile, Michael Oldani (who has since gone on to better things) has noted that a revolution occurred in the late 1990s when drug salespeople gained access to ‘script-tracking’ software. No longer did reps need to schmooze the office receptionists like Joyce with apple fritters to find out what the doctor was writing. Now with computers they could buy prescribing data, collected from pharmacies and tabulated, so that the reps could actually focus on the high prescribers and gain even more ‘face time’ to promote products. The fact that they now had the real, indisputable details of a doctor’s prescribing habits created what Michael refers to as a technology-induced ‘involution’ where major companies could do even more of what ‘works’: swarm high prescribers by even more representatives and gifts.

And despite the controversies, the mounting lawsuits and the growing sense of unease over medicating depression, last year, Zoloft generated $3.1 billion in sales.

Alan Cassels is currently a drug policy researcher affiliated with the School of Health Information Sciences at the University of Victoria. This article is based on research conducted for a book he is co-authoring with Australian journalist Ray Moynihan. Selling Sickness, about the role of the pharmaceutical industry in helping to create and market illness, will be published later this summer. References for any of the work cited may be obtained from the author at alan@alancassels.com.

Charlotte Campbell is a student at the University of Victoria’s Visual Art department.