Psychiatric drug critic Joanna Moncrieff and biomedical model champion Dr Trevor Turner were talking on the Today programme this morning. The bone of contention is Moncrieff’s assertion, that we should not consider psychiatric drugs to be correcting an inherent ‘chemical imbalance’ and thus correcting a physiological abnormality, but rather to be drugs that alter brain states sometimes in a useful way. I quite like this approach, it seems more humble and moves away from a ‘disease and correction’ model toward a more pragmatic symptom based model, which may be more compatible with non-pharmaceutical intervention.
Today discussion – 15 July 2009
Moncrieff’s paper – How do psychiatric drugs work?
Co-incidentally, I’ve volunteered to oppose the motion ‘this house believes that our lunch should continue to be funded by the pharmaceutical industry’ at a meeting today. The ‘no free lunch’ debate is an ongoing one arising from concerns that pharma’s influence on doctors leads to a medical model biased towards ever increasing prescribing, a situation which is better for the pharmaceutical companies than for our patients or wider society.
Here is it, as ever I’d like to know what you think, unfortunately unless you comment in the next 30 minutes I’ll be unable to change the text!
I wish to oppose the motion “this house believes that our lunch should continue to be funded by the pharmaceutical industry”. This is important for both our independence as doctors and is in the interests of our patients. I will outline here why we should be wary of the pharmaceutical industry and why we should not accept their hospitality;
First a bit of history. Before the 1930s doctors were pretty useless. We had insulin, morphine and had worked out the benefits of conducting operations in sterile conditions, but that was about it. Then miraculously an era of advancement between 1930-1970 produced an impressive array of medical cures such as antibiotics, transplants, ITUs, dialysis and during this time pharmaceutical companies grew big by producing and promoting innovative medicines for major diseases.
However of recent years it has become ever more difficult and expensive for these companies to repeat such successes and the number of genuinely innovative new products being released by them has significantly reduced. I would argue that the continuing benefits of prior triumphs have led us to view pharmaceutical companies in the positive light of their past achievements, and we do not sufficiently scrutinize their current practice.
Today’s situation is that faced with maintaining their profits without the support of truly innovative products, pharmaceutical companies have engaged in refashioning and repackaging old products as ‘innovations’ and, worse, identifying and promoting new diseases for their medicines. Many of the truly innovative treatments that have emerged in recent years have come from the funding of public bodies, whilst pharmaceutical firms have concentrated on ‘me-too’ drugs which aim simply to gain footholds in established and lucrative markets.
Psychiatry is particularly vulnerable to drug company tactics. Our sketchily defined diseases provide opportunities for increasing product sales as they allow scope for expanding definitions of sickness, for instance depression, social phobia, female sexual dysfunction, to include more and more areas of social and personal difficulty not previously within the medical realm and thereby sell more medication. Overall this has been a very successful tactic and antidepressant prescribing increased 173% from 1991 to 2001. The UK’s overall drug spending has increased from 3.9% GDP in 1960 to 7.7% GDP in 2002.
There are other concerns too. The industry’s heavy involvement in the organisation of research into psychiatric drugs and the dissemination of research findings raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. They also seek to gain advantage by political lobbying and funding drug-friendly patient support groups. There has been disquiet about the burying of negative trials and over the exaggeration of drug benefits as newer expensive treatments such as SSRIs and atypical antipsychotics have not proved more effective than older and cheaper alternatives.
Pharmaceutical companies have thus sold us a reductionist biomedical model of the world. They haven’t done this on their own of course, as it suits the purposes of many to live in a world where there are simple problems requiring simple solutions, but they have done their best to make sure that their voice is heard above any of those that might provide an alternate, non pharmaceutical vision. For human beings can survive without endless drugs to cure every possible ill, but the companies that prescribe them cannot. Pharmaceutical companies are primarily commercial concerns, and their major motivation is maximizing their profits.
But does this knowledge necessarily stop us accepting a free lunch from the dark side? After all it saves us from buying our own thus allowing us to conserve funds in these uncertain times. Can we not use our contact with pharmaceutical company representatives to evaluate what they tell us and learn about their products?
I argue no and for one simple reason: because we are weak.
Ask yourself this question: why would a commercial company, to whom profits are key, spend money on buying us lunch if they felt it would make no difference to our behaviour? The answer is that they wouldn’t. They know that by their engagement with us they can persuade us to use their products despite any other reservations we might previously have had. They know that they can influence us to choose the treatment that is best for them, and not necessarily best for the patients we seek to treat.
You don’t need to believe me on this one. Believe the authors of an article in the JAMA, who found that meetings with pharmaceutical representatives were associated with changes in prescribing practice. And the next time you use your sponsored pen, consider an article in the Am J Bioethics, which concluded that ‘considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize’.
The true situation is that pharmaceutical companies realize that in order for their products to find a market, they must first influence doctors to prescribe them and they spend a lot of money ensuring this takes place. From early in our careers they win our favour by providing small gifts, and by taking part in medical education seek to inculcate us with their world view.
We should realise our vulnerabilities and not tempt ourselves so. I’m not saying that drugs have no place in modern medical health care. What I am saying is that as doctors we have but one duty, and that is toward improving the health of our patients; any action we may take to place ourselves at the risk of being influenced by another competing agenda is unwise and should be avoided.
For these reasons I commend you to join with me and oppose this motion. Thank you.
Jackie Law Big Pharma – a comprehensive guide to this subject