Drug Shills Dispensing Pills

A psychiatrist questions Big Pharma’s influence on her profession.

Jean Kim November 27, 2014

(Illustration by Kat Leyh)

In 2009, as an eager young psy­chi­a­try pro­fes­sor at New York-Pres­by­ter­ian Hos­pi­tal, I pre­sent­ed to fac­ul­ty on the need for a moral dimen­sion to psy­chi­atric diag­noses. I was laughed out of the room.

By mid-decade, academic psychiatry had become glamorous. Drug reps, selected for their looks and charm, were the popular, beautiful best friends we geeky docs never had.

One psy­chi­a­trist, a schiz­o­phre­nia spe­cial­ist, said he didn’t see the point. The act­ing med­ical direc­tor said he felt I’d called him immoral. A top research psy­chi­a­trist said, incred­i­bly, Moral­i­ty and psy­chi­a­try should be kept separate.”

So a few years lat­er, when ProP­ub­li­ca launched its Dol­lars for Docs data­base to track the drug com­pa­ny mon­ey doc­tors were tak­ing, I typed in their names. The act­ing med­ical direc­tor received $12,550 in 2010 and 2011 for speak­ing gigs. The researcher received more than $212,489 between 2009 and 2012 for speak­ing gigs and con­sul­ta­tions. The schiz­o­phre­nia spe­cial­ist made more than $323,300. And the data­base only includes dis­clo­sures from 17 of the more than 70 drug com­pa­nies in the world. Accord­ing to Dol­lars for Docs, hun­dreds of thou­sands of doc­tors have raked in a total of more than $4 bil­lion since 2009, with the top earn­er, psy­chi­a­trist Dr. Jon Draud, net­ting at least $1.2 million.

As a psy­chi­a­trist who grew up” in the last decade, I was not surprised.

I start­ed my res­i­den­cy train­ing in New York City in 2000. Lunch­es and din­ners pro­vid­ed by drug com­pa­ny reps were asta­ple of my diet. For a hun­gry, har­ried res­i­dent on a pal­try salary, a free pit stop at a steam­ing Chi­nese buf­fet was heav­en. All around me in Man­hat­tan, invest­ment bankers and fresh­ly mint­ed lawyers were liv­ing it up, and I admit that I want­ed a piece of the pie as well. By mid-decade, aca­d­e­m­ic psy­chi­a­try had become glam­orous. A res­i­dent might schmooze with a drug rep and get invit­ed to a trendy spot — Nobu, Olives, Tao — where we could imbibe Sex and the City-style cock­tails and sam­ple the fresh­est sushi. Drug reps, select­ed for their looks and charm, were the pop­u­lar, beau­ti­ful best friends we geeky docs nev­er had.

In 2003, I won a free ride to the Amer­i­can Psy­chi­atric Asso­ci­a­tion annu­al meet­ing in San Fran­cis­co as part of an Aven­tis-spon­sored fel­low­ship for women in psy­chi­a­try. An indus­try-spon­sored gala fea­tured an open bar and a Brob­d­ing­na­gian spread: tables loaded with huge flower dis­plays, choco­late foun­tains, petit fours and gourmet hors d’oeuvres. The con­fer­ence also host­ed a Dis­ney-esque exhib­it hall full of bright­ly col­ored drug com­pa­ny dis­plays with touch­screen com­put­er sta­tions. I filled my free tote bag with gifts — pens, laser point­ers, can­dy, text­books. My favorite was the Xanax XR clock, whose hands rest­ed on a bed of clear turquoise flu­id, to sim­u­late the feel­ing of float­ing on a sum­mer pool.

I grad­u­at­ed from res­i­den­cy train­ing and became an attend­ing psy­chi­a­trist myself. Back then, it was viewed as a sym­bol of aca­d­e­m­ic prowess to be on a drug company’s speaker’s bureau. So when an enthu­si­as­tic new drug rep from my alma mater invit­ed me, a low­ly junior attend­ing, to a speak­er train­ing ses­sion, I was flat­tered and accept­ed. On an all-expens­es-paid two-day train­ing trip to Chica­go, I stayed at a posh hotel on Michi­gan Avenue and sat through lec­tures about the then-new antipsy­chot­ic drug Geodon. I was paid $2,500 for going, and anoth­er $1,000 for giv­ing a talk” for about sev­en min­utes a few weeks lat­er at a din­ner with a hand­ful of col­leagues. Per­suad­ed that I need­ed to gain expe­ri­ence with Geodon so that I could be a bet­ter pre­sen­ter, I began pre­scrib­ing it more often. Then I began to see that it was less reli­able than oth­er med­ica­tions. I quit the speaker’s bureau, real­iz­ing I had been manip­u­lat­ed into writ­ing more Geodon pre­scrip­tions. In fact, the drug rep’s salary depend­ed on such per­for­mance increas­es. Drug com­pa­nies can track all physi­cians’ pre­scrip­tions — a 2011 Supreme Court deci­sion upheld their right to do so, cit­ing data as free com­mer­cial speech.”

In Novem­ber 2007, as the econ­o­my implod­ed, a promi­nent psy­chi­a­trist, Dr. Daniel Car­lat, wrote a famous essay in the New York Times Mag­a­zine about a stint as a phar­ma shill. He con­clud­ed, The mon­ey was affect­ing my crit­i­cal judg­ment. I was will­ing to dance around the truth in order to make the drug reps hap­py. Receiv­ing $750 checks for chat­ting with some doc­tors dur­ing a lunch break was such easy mon­ey that it left me gid­dy. Like an addic­tion, it was very hard to give up.” I read it and real­ized that I had been going along with the tide — that a colos­sal, prof­it-dri­ven adver­tis­ing engine was using our own psy­cho­log­i­cal tac­tics to manip­u­late us.

The next year, heads began to roll. In Octo­ber 2008, Dr. Charles Nemeroff, then head of psy­chi­a­try at Emory Uni­ver­si­ty, made the front page of the New York Times for fail­ing to report more than $1.2 mil­lion dol­lars in drug com­pa­ny-relat­ed income to Emory, which had strict guide­lines for non-aca­d­e­m­ic mon­ey. He resigned and now works for the Uni­ver­si­ty of Miami. 

Dr. Joseph Bie­der­man of Har­vard Med­ical School went one step far­ther than Nemeroff. As the Times report­ed in Novem­ber 2008, he not only hid from Har­vard that he’d tak­en more than $1.4 mil­lion from drug com­pa­nies; he pub­licly advo­cat­ed for diag­nos­ing more chil­dren with bipo­lar dis­or­der and pre­scrib­ing them more antipsy­chot­ic med­ica­tions. The rate of pre­scrip­tions for these med­ica­tions sky­rock­et­ed. Antipsy­chotics should only be used when absolute­ly nec­es­sary, giv­en their poten­tial for seri­ous side effects, espe­cial­ly in children.

Since then, FDA reg­u­la­tions have got­ten tighter, and in 2009, the Phar­ma­ceu­ti­cal Researchers and Man­u­fac­tur­ers of Amer­i­ca self-imposed a code on inter­ac­tions with health­care pro­fes­sions. Drug com­pa­ny speak­ers can no longer ad-lib invent­ed uses for their med­ica­tions and have to include men­tion of neg­a­tive stud­ies” if avail­able. Comped din­ners must be mod­est by local stan­dards and include pre­sen­ta­tions. Pens and trin­kets are banned. The once-charm­ing reps can speak to you only if spo­ken to, not unlike vam­pires who can­not enter your home unless invited.

The reforms have cut down on bla­tant phar­ma influ­ence, but promi­nent psy­chi­a­trists still shill shame­less­ly, and much research is phar­ma-fund­ed. Take the Octo­ber 2014 issue of the Amer­i­can Jour­nal of Psy­chi­a­try, the elite sci­en­tif­ic pub­li­ca­tion in our field. Five of the six research arti­cles con­tain dis­clo­sures that one or more of the authors worked or con­sult­ed for phar­ma. It remains to be seen whether more data releas­es from ProP­ub­li­ca—and now from Open Pay­ments, a fed­er­al data­base man­dat­ed by the Afford­able Care Act and unveiled in late Sep­tem­ber — will cre­ate enough pub­lic back­lash to con­vince these doc­tors that this type of income does harm. Con­flicts of inter­est weak­en the cred­i­bil­i­ty of research and hurt patients by encour­ag­ing poor pre­scrib­ing prac­tices. They also under­mine the cru­cial trust between doc­tor and patient by fuel­ing the para­noiac skep­ti­cism that all psy­chotrop­ic med­ica­tions are mind-alter­ing, tox­ic tools of profit.

The right med­ica­tions, along­side psy­chother­a­py, can save and improve lives. I have seen peo­ple frozen in psy­chosis or melan­cho­lia awak­en, as though from a night­mare, after get­ting the right treat­ment. I have seen sol­diers back from war, rid­dled with flash­backs, become able to do sim­ple things again, like go to a shop­ping mall. I have seen peo­ple once stuck in hos­pi­tals able to work again, to fin­ish school, to have lov­ing rela­tion­ships. Those moments ful­fill me as a doc­tor and as a human being. But I wish my pro­fes­sion would rec­og­nize that our ethics are worth more than a quick buck.

a psy­chi­a­trist and writer in Wash­ing­ton, D.C., who is fin­ish­ing her M.A. in non­fic­tion writ­ing at Johns Hop­kins University
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