Tag Archives: American Psychiatric Association

Drug Companies Do-Si-Do at Diabetes Meeting

I don’t really walk around with antennae out trying to detect pharmaceutical company influence on physicians, despite this being my second blog post on the topic in the past month. (See the earlier one here.) But I couldn’t help thinking about it when I arrived at the American Diabetes Association 2011 scientific meeting and found that the registration packet included a 40-page booklet produced by the ADA but focused on “Corporate Events.”

Cover of a book in the ADA attendee materials. (Photo by Sherry Boschert)

Most large medical conferences will have satellite symposia driven by drug companies, but I don’t think I’ve ever seen them given the same packaging treatment as the scientific sessions.

Why does this bother me? Well, the day after I returned from that meeting, the media widely reported on a study and several papers in The Spine Journal questioning the validity of years of industry-sponsored research that had led doctors to believe that a bone growth protein often used in spinal fusion surgeries was safe. The review led by Stanford University researchers concluded that bone morphogenetic protein may cause a variety of complications, even permanent or potentially fatal ones, at rates 10-50 times higher than reported. After the news coverage, the authors called out what they considered deceptive back-pedaling by the companies and a doctor who profited from it all.

Granted, that’s not the diabetes world, but having such an apparently cozy relationship between industry and the ADA probably isn’t a good thing in the end. Except that I imagine it might have helped pay for the truly delicious, healthy food they fed us in the press room.

On the other hand, there are signs of potential progress in disclosing drug company influence on the practice of medicine. Nearly all medical conferences I cover now religiously require speakers to list disclosures of conflicts of interest and make these accessible in printed form for all conference attendees. That’s a big improvement over the days when I’d have to request the information and spend a couple of hours flipping through the single three-ring binder containing disclosures.

And back at the American Diabetes Association meeting, I saw something else unusual that I had seen only once before, at the 2011 American Psychiatric Association meeting. In the Exhibit Hall, one of the pharmaceutical giants was giving away free fruit smoothies — nothing unusual in that. But the smoothie stand featured a sign saying the following:

“The cost of any refreshments, meals or educational items provided to U.S. licensed Healthcare Professionals attending this [company] Exhibit will be subject to public disclosure on [the company’s Website] as part of [the company’s] Healthcare Professional Disclosure policies, and may also be subject to disclosure by state governmental authorities pursuant to your state law. In order to comply with these requirements, please make your badge available to be scanned by an attendant as requested.

“If you hold a Healthcare Professional license in Minnesota, we are prohibited from providing you any refreshments or items of value due to your state limitations and ask that you do not partake in the hospitality provided.”

No need to feel sorry for Minnesota physicians, though. No such signs tried to dissuade them from filling up on coffee and lattes from numerous other company booths in the Exhibit Hall. Apparently smoothies may cross a “hospitality” threshold for disclosure that java does not.

–Sherry Boschert (@sherryboschert on Twitter)

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Filed under Cardiovascular Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Internal Medicine, Orthopedic Surgery, Practice Trends, Primary care, Psychiatry

Does Drug Company Marketing Affect Sales of Antidepressants?

Selective serotonin reuptake inhibitor (SSRI) drugs are the most commonly prescribed antidepressants, and any one SSRI is about as good as another SSRI in treating depression, studies have shown. Generic SSRIs are about half the cost of branded ones, however, so you might expect that generic SSRIs would be prescribed at higher rates than SSRIs that are still under patent by the drug companies.

Photo from National Photo Company collection at Library of Congress (Wikimedia Commons)

Funny thing, though — a Canadian study found that as soon as the patent expires on an SSRI and the drug goes generic, sales drop significantly, Dr. James M. Bolton and his associates reported at the annual meeting of the American Psychiatric Association.

They analyzed data on all dispensations of SSRIs in Manitoba (population 1.2 million), from 1996 to 2009 and graphed the number of prescriptions filled in pharmacies for each SSRI in the pre- and post-generic periods after adjusting for the effects of age, sex, income, and provincial region.

Among the four SSRIs that were on the market in 1996, sertraline went generic in 1999, fluoxetine’s patent expired in 1994, fluvoxamine went generic in 1996,  and a generic form of paroxetine became available in 2003. Citalopram entered the market in 1999 and went generic in 2003.

For every quarter that sertraline was a branded drug, the prescription rate increased 4.6%, and every quarter as a generic drug the prescription rate decreased 1.5%, a statistically significant shift in the usage trend, said Dr. Bolton, of the University of Manitoba, Winnipeg. Paroxetine’s prescription rate increased 4.7% in every quarter as a branded drug and decreased by 1.9% each quarter as a generic, which also was a significant change.

Dr. Bolton (Photo by Sherry Boschert)

The shift with citalopram was even more dramatic, from a 13.2% increase in prescriptions every quarter it was under patent to a 1.3% increase per quarter after going generic, a 10-fold drop. Pre-generic data were not available for fluoxetine or fluvoxamine, which showed 0.8% and 2.9% decreases per quarter in prescription rates in their post-generic eras.

Essentially, prescriptions favored whichever SSRI was under patent in any particular year, even though much less expensive generic SSRIs were available. General practitioners were more “enthusiastic” about prescribing branded SSRIs than were psychiatrists when both branded and generic forms were available, Dr. Bolton said. Factors other than cost and efficacy seemed to be driving usage, which is concerning given the financial constraints of a public health care system like Canada’s.

Why was this happening? It could be that physicians or patients believed that generics were not as effective as branded SSRIs and didn’t practice evidence-based medicine. Or maybe they were spooked by Health Canada regulatory warnings about possible associations between SSRI use and suicidal behavior, though you’d think that fear would apply to both branded and generic SSRIs.

A third explanation may be the influence of drug company promotion for the branded SSRIs that give them the most profit. In the United States in 2005, pharmaceutical companies spent more than $1 billion to promote SSRIs and serotonin noreprinephrine reuptake inhibitors (SNRIs), including $68 million on physician detailing, Dr. Bolton said. Of the $16.8 billion spent on antidepressant prescriptions in the United States in 2009, $14.2 billion was for branded drugs, he added.

The findings of this Canadian study, however, don’t necessarily apply to the United States, he said. Many U.S. managed care organizations mandate use of less expensive SSRIs instead of more-expensive options. In Canada’s universal health care system, care is free but patients pay out of pocket for medications, so many people buy insurance plans to manage their medication costs. Drug prices do matter to patients on both sides of the border.

Physician detailing isn’t the only way to influence prescribing practices, and news accounts are becoming more common about efforts to separate physicians from drug company influence. Stanford University School of Medicine recently censored five faculty members for violating its conflict-of-interest policy against taking drug company money in exchange for promotional speeches, ProPublica reported.

With control of health care costs near the tops of both U.S. and Canadian politics, I think we’ll be hearing more reports like these.

— Sherry Boschert

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Psychiatric Hospital’s Bicentennial Offers Glimpse of the Past

The first psychiatric hospitals in the United States brought a revolutionary perspective toward people with mental illness — the idea that the aim was to cure, not to subdue. McLean Hospital’s celebration of its 200th year in 2011 is great fodder for mulling over the psychiatric care of the past, and for trying to imagine psychiatric facilities of the future.

The first graduating class of McLean Nursing School, 1886. (Photo courtesy of McLean Hospital)

The third oldest psychiatric hospital in continuous operation in the United States, McLean was founded on the same day as Massachusetts General Hospital in 1811, but opened its doors 3 years before the general hospital, Adriana Bobinchock told me at the American Psychiatric Association annual meeting. Today, McLean Hospital is the largest psychiatric affiliate of Harvard Medical School and partners with Massachusetts General and Brigham and Women’s Hospitals, said Ms. Bobinchock, director of public relations for McLean Hospital.

The only older continuously operating psychiatric hospitals in this country may be Eastern State Hospital, founded in 1773 in Williamsburg, Va., and Spring Grove Hospital Center, founded in Catonsville (near Baltimore), Md. in 1797.

The old McLean Asylum, mid-1880s. (Image courtesy of McLean Hospital)

A brief history of McLean Hospital contains an eclectic collection of “firsts.” It opened the first psychiatric school of nursing in 1882. It was the first U.S. psychiatric hospital to open research laboratories. And it’s the origin of the nursery song, “Mary Had a Little Lamb,” which was inspired by one Mary Sawyer, an attendent at the McLean Asylum for the Insane (as it was then called) in 1832 who had, indeed, been followed by a lamb to school.

Animals played an important role at the asylum, which evolved into the hospital. Until as recently as 1944, it operated as a nearly self-sustaining community, with a farm, a blacksmith, and an upholstery shop. The asylum originally was located in bucolic Somerville, Mass., because the quiet, rural environment was thought to be therapeutic. Before long, urban encroachment wrecked the peace, including two railroad lines that cut through the grounds, so the facility moved to new grounds in Belmont, Mass., where it remains today. The hospital has grown from seeing 13 patients in its first 3 months to now admitting more than 9,000 adults and children each year to inpatient and residential levels of care, as well as providing more than 58,000 day-treatment and outpatient visits per year in seven satellite programs around Massachusetts.

Otto Folin in the McLean Hospital biochemistry lab, 1905. (Photo courtesy of McLean Hospital)

The psychiatric diagnoses of 1811 bear little resemblance with today’s diagnoses of mental illnesses. Watch the brief video interview with Ms. Bobinchock (below) to hear some of the reasons patients first came to McLean. It all makes me wonder how we’ll conceptualize mental illness another 200 years down the road. This year, when proposed revisions in the DSM-V will greatly rearrange some of our current diagnostic categories, it’s not hard to imagine that we’ll be using very different descriptions of mental illness even 50 years from now, much less 200.

 And I wonder if some of the characteristics of yesteryear’s asylums might return in the future. Will a connection with nature be fostered as a healing force? Will communities increasingly be expected to be self-sustaining? Will we have cures for the worst psychiatric illnesses, so that no ever need be “subdued”?

How do you imagine “psychiatric hospitals” in the future?

–Sherry Boschert

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Sports concussions leave sneaky side effects

When he was a teenage lacrosse player, Dr. Brandon Cornejo suffered a mild concussion. He was awake during the trip to the hospital in his parents’ car. And he painfully recalls the resulting cognitive and emotional side effects that messed him up academically, socially, and psychologically.

Lacross sticks image by Yarnalgo (Wikimedia Commons).

The worst part, though, was that he spent 16 years not even knowing he had suffered the traumatic brain injury, because he had no memory of it. He wasn’t aware of a “before” or “after” the injury, so he didn’t know that his struggles were caused by the concussion. Instead he blamed himself, floundering in anger, confusion and depression.

Now a chief resident in psychiatry at the University of Wisconsin, Madison, Dr. Cornejo told his story at the annual meeting of the American Psychiatric Association to impress upon his colleagues the challenges of helping patients with traumatic brain injury, especially athletes.

“These mild injuries can have profound effects on your self-concept and your experience as a human being. They can change the course of your life,” he said.

In 1991, he was a straight-A student in his junior year at a college preparatory high school and the son of proud Latino parents who had never attended college themselves. He and his family were looking forward to him getting a scholarship to finance college.

Dr. Cornejo (Photo by Sherry Boschert)

After the concussion, his grades tanked. He barely got by with Cs and Ds. His girlfriend dumped him. He became very emotional. He remembers 6-9 months of bad fights with his parents. “The likelihood is pretty high that this was related to the loss of consciousness,” he said. “For years, I considered myself `not good at’ certain things because of my academic performance in my senior year.”

His behavior frustrated and shocked him. One time he exploded in “road rage,” which embarrassed him even though no one was there to witness it. Another time when he was ordering oatmeal in a restaurant, he could not recall the words for brown sugar.

“I developed a significant depression, a huge depression. In retrospect, I have a hard time distinguishing between depression produced by traumatic brain injury and depression because I wasn’t performing academically. My family was counting on” a scholarship, he said. That motivation and a lot of hard work eventually got him back on track academically, and somewhere in his freshman year of college he started to regain some self-esteem.

Years later, in 2007, his father casually said, “Remember that time you got knocked out, and we took you to the hospital?” Dr. Cornejo could dredge up only two memories — one of his coach staring down on him on the field, and the other of being in the back seat of the family car, with his mother saying, “Brandon, you’re really scaring us. Why do you keep repeating yourself?”

At the time of the injury in 1991, understanding of traumatic brain injury was just beginning to emerge, and the primary care physician who saw him for follow-up told his parents that their son should be fine, and they should keep an eye on him for a couple of weeks.

Today, Dr. Cornejo hopes that physicians would not allow young athletes with traumatic brain injury to return to play as quickly as he did, because repeat concussions carry much higher risks. He wishes that helmet designers would improve their products. And he urges all physicians to educate not only patients but their families and significant others about the potential sequelae of traumatic brain injury.

Because the patients may not remember.

–Sherry Boschert  @SherryBoschert on Twitter

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Psychiatrist: Not Well Liked? Never Mind.

To actress Sally Field, being well-liked is really, really important, as evidenced by her emotional acceptance speech for an Oscar win in 1985.

Image via Flickr user Alan Light by Creative Commons License

But if you’re a psychiatrist treating patients with bipolar disorder, your likeability quotient shouldn’t be keeping you up at night.

What really matters in your business, according to a new study from Massachusetts General Hospital, is whether your patients feel understood, respected, and listened to. If they do, they’re more likely to take the medications you prescribe, as prescribed, a key factor in stablizing patients with the disorder.

Louisa G. Sylvia, Ph.D., associate director of psychological services at the hospital’s Bipolar Clinic and Research Program, examined the relationship between medication adherence and assessments of psychiatrists by 3,640 patients enrolled in the STEP-BD trial.

When patients felt they had a good working relationship with their psychiatrists and “meaningful exchanges,” they tended to stick close to the medication plan prescribed for them.

One important element of collaboration, for example, was being told that they had the right to refuse treatment.

“I interpret that as collaboration,” said Dr. Sylvia during a scientific presentation of her results at the annual meeting of the American Psychiatric Association. When a give-and-take discussion preceded prescribing, “They were actually more attached to the treatment.”

Liking the psychiatrist “as a person” was not a key factor associated with adherence, nor was a patient’s sense that the psychiatrist had experience in helping people.

But another key to success, perhaps a simple sign of respect, was promptness, according to the study. Patients kept waiting longer than 15 minutes beyond their appointment time were more likely than others to be nonadherent to their medications, Dr. Sylvia reported.

—Betsy Bates
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Tears When a Patient Takes the Podium

From the annual meeting of the American College of Obstetricians and Gynecologists.

Mary Jo Codey (Photo courtesy of Robert Menendez Senatorial Office.)

When physicians invite patients who have become advocates to speak at medical conferences, there’s usually a good reason. I’ve learned a lot from hearing a panel of intersex people speak at a meeting of psychiatrists and psychologists, and I’ve always been moved by hearing people who are living with HIV and AIDS address physicians, whether in small grand rounds or at the International AIDS Conference.

My jaded professional demeanor was blown apart, though, when I heard Mary Jo Codey speak this week. My eyes teared up. The eyes of physicians all around me teared up. When she finished, thousands of ob.gyns. in the auditorium gave her a standing ovation.

Codey, an elementary school teacher who loved children, suffered postpartum depression with both of her two pregnancies. She described the agonizing ordeal she went through before she was diagnosed, the multiple failed antidepressants and electroshock therapy, the judgmental attitudes that made her blame herself, the desire to hurt her baby, the desire to kill herself.

“Nothing that has happened in my life was worse, not even breast cancer and a double mastectomy. They can’t even compare,” she said. Finally, treatment with a monoamine oxidase inhibitor restored her mental health. When her husband later became governor of New Jersey, she launched a statewide campaign to raise awareness about postpartum depression and to improve education and resources on the subject.

The president of the American College of Obstetricians and Gynecologists, Dr. Gerald F. Joseph Jr., has made postpartum and perinatal depression part of a “presidential initiative” that included release last fall of a joint report with the American Psychiatric Association on Management of Depression During Pregnancy. In early 2010, the College also released a committee report on screening for depression during and after pregnancy.

By focusing the entire opening plenary session of the annual meeting on this topic, he sent a message about the importance of getting ob.gyns. to wrap their minds around the issue of postpartum depression. And by having Mrs. Codey speak, he guaranteed that they wrapped their hearts around it, too.

—Sherry Boschert
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Indecent Disclosure?

From the Digestive Disease Week, Chicago.

Walking around McCormick Place this week, one was struck by what was — and was not — in evidence, given all the hoo-ha over conflict of interest in medicine these days.  In the last few years, attendees were heaped up with purple-festooned items emblazoned with “Nexium“, the ubiquitous “Purple Pill” that is probably one of the most over-prescribed pharmaceuticals in America.  

Where have all the sponsors gone?/Photo by A. Ault

Where have all the sponsors gone?/Photo by A. Ault

But this year, there was a severe shortage of gee-gaws, both at the registration desk and in the exhibit hall.  I mean, not a single squeeze toy, pen or post-it note pad.  The official DDW bag was a chic black cotton number.  No drug company names, no embarassing slogans, just “DDW” and the cryptic acronyms for the four sponsoring professional societies.

Dianne Bach, DDW’s industry liaison, said the societies did not have any official new sponsorship policy, but that they had decided to follow the Pharmaceutical Research and Manufacturers of America guidelines on industry support that went into effect in January.  That means that sponsorship of lanyards, carry bags, ID tags, pens, and the like were out.

DDW still had to offset that lost revenue, however.  The organization determined that drug company sponsorship of shuttle buses was OK.  And, for the first time, says Ms. Bach, DDW allowed large banners in the convention center hallways.

Purple banner/Photo by A. Ault

Purple banner/Photo by A. Ault

Still, DDW’s addressing of the conflict issue is a far cry from moves made by other professional societies. The American Psychiatric Association recently said it would no longer allow industry-supported symposia at its annual meeting.  DDW, however, has no plans to end those off-site seminars, says Ms. Bach.

And then there’s the matter of speaker disclosures.  DDW compiled a list of presenter disclosures, but don’t look for it in print.  The organization decided that at 180 pages, an on-line only version would be cheaper. 

At many sessions I attended — and i heard the same thing from a few other reporters — speakers only made glancing reference to their conflicts.

Now that’s what I’d call an indecent disclosure in this day and age. 

— Alicia Ault  (on Twitter @aliciaault)

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