Posted by alexandra_k on May 17, 2009, at 0:21:32
The state of psychiatry really is quite frightening. I started out working on trying to justify psychiatry's status as a branch of medicine (in the face of the anti-psychiatry critique) and the more I read about the history and current state of psychiatry (by reputable theorists) the more concerned I became. But then turning to medicine more generally the more I read about the history and current state of medicine (by reputable theorists) the more concerned I became about that too. And then similarly, reading about the current state of science (and seeing it in action myself by attending seminars etc) is similarly frightening in some respects. The main driver for medical research really does seem to be extra-scientific rather than scientific concerns. I think... It basically pollutes the science and... People suffer / are harmed because of that.
Disregarding or undermining what someone has to say on the basis of who they are (or what ulterior motives they may have for their position) is known as an `ad hominum attack'. It is thought to be unjustifiable to disregard or undermine what someone has to say SOLELY on the grounds of who they are or what ulterior motives they have. It is considered reasonable, however, to examine the grounds that a person has for saying what they say when they do have some obvious stake in what it is that they are saying. If an economist makes a recommendation for a policy where they will financially profit if the recommendation is implemented that provides us grounds not for disregarding what they have to say in virtue of the stake that they have, but grounds for really examining the reasons they have for what they have to say in order to assure ourselves that the reasons are good and that the person didn't come to the view that their recommendation was best solely on the grounds that it would profit them. The obvious way to check is to employ people who are genuinely INDEPENDENT (and non-corruptable) who are knowledgeable enough in the relevant field to uncover problems with the methodology or conclusions inferred from the findings etc. People who aren't subjected to advertising and freebies. Both the FDA and the scientific peer review process are infected by the same problem, however. They watch TV. They get their freebies. They get their 'informational sessions'. They have investments. It is hard to find people who truly are independent.
There is a significant pharma investment in health research. In psychiatry, in medicine, and in science more generally (including in university contexts). That psychiatrists, medical doctors, and scientists have financial ties to pharma (in the form of free lunches, sponsored conferences, stationary, samples, and investments in companies) doesn't itself undermine their `findings' or `recommendations' or `prescriptions' but it does give us sufficient grounds to hold their opinions up for greater scrutiny. Especially because the opinions have such a significant impact on peoples lives. At the moment `undeclared' financial interests are rife (a person doesn't have financial investment in a pharma company they have some investment in some subsidiary that isn't itself a pharma company and so on). There is a historical process whereby a new `wonder drug' is invented and considerable profits are made. Problems begin to emerge and pharma dissociate themselves from the problems with their products. About 10-15 years later (once the drug is out of patient) the problems are acknowledged. Reexamination of the scientific literature that was used to support the acceptability of the product is now reinterpreted such that the considerable problems with it really were apparent all along. The problems with the product are then used as the basis of an advertising campaign for the superiority of the next `wonder drug'. Over and over and over... There is no reason to think that things have changed. I was astounded that the majority of student psychiatrists on the student doctor network thought that accepting freebies from pharma didn't have any impact on their prescribing practices and that attending pharma sponsored `informational sessions' was the best way they had of keeping up with the `current state of knowledge' in the medical field. I hope they are not representative, but my fear is that they are.
Pharma makes significant profits. They make profits to the extent that they are able to `reinvest' millions or billions of dollars every year into advertising (both to medical practitioners and to the general public). Given the considerable profits they make I'm sure they employ some of the best market researchers in the world in order to figure out the best way of them to maximize their profits by way of advertising. It really is unthinkable that they would invest so heavily in advertising if they didn't (on average) make more money from sales in virtue of that investment than they would make if they didn't invest those funds in that way. Advertising really does have the power to alter consumer (and prescriber) behavior. If it didn't companies wouldn't invest in it. It really is astounding to me that potential doctors wouldn't know that there really is `no such thing as a free lunch' and that sometimes `a pen is not just a pen'. They might think that they can simply eat their lunch and sleep through the following 'informational session' (when they aren't attempting to say that is the best contact they have with current scientific research) but the market research surely tells us that that is not the case. Similarly with the 'familiarity effects' of advertising on stationary.
It would be easy enough to manipulate advertising to the consumer and to doctors in order to see what impact that has on both consumer demand and doctors prescribing practices (and the significant relationship between them given that consumer satisfaction co-varies significantly with the patient being prescribed the brand they request). In fact such an experiment was done in New Zealand (with respect to a temporary ban on DTC - direct to consumer - advertising of medications (note: not of medical `conditions'). I think this followed some serious f*ck up with a new 'once a day' asthma inhaler that resulted either in a number of deaths or near deaths and physicians felt that their decision to switch from what was a basically effective medication to a medication where efficacy for their patient was unknown but where convenience to patient was advertised to be significantly greater was driven by consumer demand. New Zealand is often used as a test market for advertising research because it costs (relatively) a lot less to launch a nationwide advertising campaign there and it turns out to be highly predictive of consumer behavior in Australia, Canada, the UK, and the USA. A ban on DTC advertising was never trialed or implemented in those other countries because pharma profits would have been way down (due to consumers preferring and reporting higher satisfaction with either generic with their current or with alternatives to medication). Pharma was not happy with the trial and the results of it aren't widely disseminated (interestingly enough a number of doctors felt strongly that the trial should not have been done - something about `biting the hand that feeds you').
(In a similar vein 3 WHO organization studies showed that two thirds of people with a diagnosis of schizophrenia (the majority) recover from schizophrenia in 'developing nations' whereas only one third recover (a minority) in 'developed nations' where people have 'better access' to psychiatrists and to medications (the samples were matched for severity). The WHO couldn't believe the results of the first study (surely people should profit rather than suffer from living in a 'developed nation') and so they replicated the study again... And again... Then the basic decision was for the results not to be widely disseminated in order to preserve the intuitive truth that 'schizophrenia is a life long condition that people don't recover from despite our having access to the best standard of medical intervention in the world'. Perhaps that attitude... Is largely responsible for the finding....)
Arguments are sometimes made (and in fact were made) that pharma profits are important because the funds generated are reinvested in the developments of further products for 'medical breakthroughs'. I'm not at all convinced that the greatest medical breakthroughs have come or are likely to come from pharma rather than from the (relatively few) independent researchers that there are out there. A child dies every 30 seconds from malaria. How much pharma funds are invested in developing treatments for maleria compared to developing medications that inhibit the absorption of fats that people eat or giving people erections on demand or smoothing out peoples skin or giving them larger breasts? Once treatments are developed (e.g., for dehydration and HIV) how are those medications distributed to people? The majority of people who need the medications don't get it because they can't afford to pay the patients that pharma (falsely) says it *must* charge in order to remain viable at all. Hand outs are a small token of what they could do while remaining viable. It isn't about running a business that is viable so as to help people and it isn't about treatment for life threatening disorders. It is about profits at the end of the day and it simply is more profitable to persuade people by way of an extensive advertising campaign that relatively (to malaria, death by dehydration, or HIV) minor complaints are serious enough such that they should take the latest wonder drug for it (warning potential side effects include heart attack renal failure impotence and even death). It is about profits at the end of the day.
How did the world get to be in such a state? Is it an inevitable consequence of a 'free market' or a 'market driven economy' do you think? If so then should there be more restrictions on the extent to which the market (significantly altered by the absence of restrictions on advertising) is allowed to drive health research? Should medication decisions be like spaghetti sauce decisions where people are 'free' to make their choices on the basis of advertising and product placement? Or do we expect different when it comes to treatments for health conditions given that the potential harms are so very much greater? A number of people feel that our obligations to humanity don't cross national boundaries. I don't know... What does it mean to be a 'world leader' and what obligations does that confer (or is that simply about rights?)? What can one do to change all this? I simply don't know... Why is the world like this? I simply... Don't understand.
I wonder if a course (or two) in 'critical thinking' for future doctors that is aimed at covering the impact of advertising on consumer / prescriber behavior, the difference between advertising and information etc etc etc along with facts about the history of the rise and fall of wonder drugs and an examination of the (adequacy? inadequacy?) of the current checks that are supposed to prevent this would help doctors be more circumspect about this all... Looking through some of the data and seeing how it didn't support the conclusion that was claimed and that the problems with the product really were apparent in the study. There really need to be independent researchers whose job it is to disseminate quality research findings to medical practitioners (rather than relying on drug rep / former cheerleaders). But then there also need to be quality studies that are done by people who don't have pharma ties. At the moment people aren't even honest about their financial ties and there simply aren't serious consequences for this. That is unbelievable. Just because pharma claims 'the majority of doctors believe that depression is due to a chemical imbalance in the brain' doesn't mean that 1) They have actually done a survey of doctor opinion at all (but of course that isn't considered false advertising such that they aren't allowed to claim it if the study has not been done) even less done a representative one (such that they can legitimately generalize from their sample to 'all doctors') or 2) Doctors only believe this because pharma tells them so. Repeatedly. At every 'informational' session. Because the current health system really is so consumer driven this won't even be enough... It is just... A f*ck*ng mess. A f*ck*ng mess.
poster:alexandra_k
thread:896175
URL: http://www.dr-bob.org/babble/social/20090513/msgs/896175.html