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.
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.