One of the constant criticisms of psychiatry that it is heavily influenced by pharmaceutical companies in whose interest it is to encourage as many people as possible to take medication. This is not to say that the benefit to society from the products of drugs companies has not been massive, but we should not, simply on this basis, assume that the interest of drug companies and the desires of doctors and patients are identical. There are significant overlaps, but in one fundamental respect they come into conflict: pharmaceutical companies are answerable to their shareholders and thus above all need to maximize profit and their market share. Put another way, human beings can survive without endless drugs to cure every possible ill but the companies that provide them cannot.
Psychiatric prescribing has been a particularly rich picking for pharmaceutical companies. A large proportion of the global drugs spend is on psychoactive drug and in the UK between 1991 and 2001 prescriptions of antidepressants rose by 173%. Partly off the back of this drug companies have become some of the most profitable organizations in the world. In 2002 the combined profits for the ten drug companies ($35.9bn) in the Fortune 500 were more than the profits for the other 490 listed businesses put together ($33.7bn). As their profits have increased, so have the amount governments and individuals have spent on their products. In the UK the per-person government health care spending went up from $84 in 1960 (3.9%GDP) to $977 in 1980 (5.6%GDP) and reached $2160 in 2002 (7.7% GDP – all figures adjusted for inflation). The global spend on drugs increased from $20bn in 1972 to $500bn in 2004 (not adjusted for inflation).
Drugs are central to modern psychiatric practice and also to thinking about the nature and aetiology of mental disorders. Arguably the primacy of concepts such as depression, social phobia, attention deficit and hyperactivity disorder owe much to pharmaceutical company intervention and psychiatric disorders provide opportunities for increasing product sales as, being poorly understood, they allow scope for expanding definitions of sickness to include more and more areas of social and personal difficulty not previously within the medical realm. In addition the influence that the pharmaceutical industry wields has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. Furthermore the coercive function of psychiatry has also been strengthened by the continued promotion of the idea that that psychiatric disorders are akin to medical conditions and therefore amenable to technical solutions in the form of drugs the benefits of which we have a duty to impose.
Pharmaceutical companies spend a vast amount of money on marketing, an activity which is often aimed at doctors, on whom they must rely in large part for the distribution of their products. Sponsorship is given to academic meetings providing access to the leading doctors of the future. Although a representative’s gifts may be relatively small, even ones of negligible value can influence the behavior of the recipient in ways the recipient does not always realize. There is also disquiet about various aspects of research and the licensing process. Drug companies have repeatedly been shown to bury unflattering data. Even drug trials can be considered as a form of marketing as they introduce physicians to drugs early.
Any invective on this subject should not of course just be levelled at psychiatrists, as it effects all branches of medicine but psychiatry has arguably been one of the most vulnerable specialties. We are rapidly becoming, or indeed have become, a society that seeks a ‘pill for every ill’ and one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. But for our part as psychiatrists and doctors we should, whilst recognizing the contribution that pharmaceutical companies make, seek not to collude with practices that are against the best interests of patients and of the wider society.
For further information on this subject the following are excellent:
Is Psychiatry for sale? – the astute reader will see that I’ve pinched some of her arguments. It’s a short closely argued polemic. But be warned – I once presented it in a journal club and found few supporters.
Bad Science by Ben Goldacre. Everyone’s favourite exposer of folly has a chapter on this in his book. I note with some envy that it’s the 13th best seller on Amazon. I’d be lucky to get 13 comments on this blog in a month. One can but dream….