Making Sure Your Shrink Has Only Your Needs in Mind

Psychiatry and psychoanalysis were supposed to transform humanity for the better by allow us to understand what makes us happy, sad and crazy and to control it, rather than to let it control us. But after a century that witnessed  Woody Allen undergoing intense treatment for decades that resulted in his marrying his step-daughter (and feeling darn good about it!), the profession is increasingly resorts to a shrug and a prescription. The good news is that many of the new drugs seem to do the job a lot better than Dr. Freud’s couch; the bad is that psychiatrists are often conflicted by their financial ties to drug companies.

Writing in the current issue of the Journal of the American Medical Association, Dr. Thomas Insel, Director of the National Institutes of Health, states that American psychiatrists need to reform a “culture of influence” that has been nurtured by too many goodies offered to doctors by pharmaceutical companies and happily accepted, including big ticket items like research grants, trips, fees for writing friendly journal articles and entertainment, and smaller trinkets like coffee mugs. When it comes to telling a patient which company’s drugs to buy, a psychiatrist just might lean a little bit towards the ones that send him checks—or a lot. The bias might even tip the scales as the doctor decides whether to recommend non-drug therapy or just to tell a patient to take a pill. What must occur, Insel says, is increased transparency and attention to ethical standards.

There had to be some good stuff buried in that 3000 page health care bill, and there is. One provision requires drug companies to report the payments and gifts they make to individual doctors, so patients can check to see what companies their doctors are beholden to.

The current National Institutes of Health rules on financial disclosure are far too lax, allowing researchers to make their own judgments about what constitutes a “significant financial interest,” (this is the kind of vagueness that often comes from self-regulation) which they must report to their academic or research institutions. The rules have ridiculously high thresholds of tolerance for potential bribes, kick-backs and “persuasion,” exempting disclosures of anything below $10,000 annually or 5 percent equity interest in a company.

The new reporting requirements were spurred by the 2008  investigation by GOP Sen. Chuck Grassley of Iowa, whose hearings uncovered millions of dollars in unreported fees paid by drug industry to  researchers. Dr. Insel now believes that psychiatry may have more drug ties than other medical specialties. Psychiatric journals have higher rates of industry funding for published studies than other medical journals, and research indicates that as much as 90 percent of the advisers who help write American Psychiatric Association guidelines have undisclosed financial ties to the pharmaceutical industry.

Might all this money lead a researcher to sing the praises of one drug over another? Might that free trip to speak at a company retreat cause a psychiatrist to insist on that company’s brand rather than the cheaper generic version? Might the pay-offs lead to doctors’ preference for drugs over therapy? Congress thinks so, and so does Dr. Issel. As with all conflicts of interest, the issue is trust. A patient has reason not to trust that a psychiatrist is doing what the patient needs, based only on the patient’s needs, if drug company money might be influencing the doctor’s judgment.

Members of Congress understand how that works (cough, cough).

It would have been more fair, honest and transparent if the public could have known what was in the health reform package before it was passed, but requiring open reporting on ties between doctors and pharmaceuticals is certainly one of the provisions that deserves applause. It will help cut prescription expenditures, improve treatment, and bolster trust. Best of all, those of us who have been driven crazy by the twists and turns of the health reform battle will be a bit more secure that our shrinks’ diagnosis  will be dictated by our symptoms, and not by the logos on their coffee mugs.

3 thoughts on “Making Sure Your Shrink Has Only Your Needs in Mind

  1. You only have to look at the job statistics to see the truth in these matters. Before the previous rules went into effect (3-4 years ago), being a drug rep to doctors (drug pusher in industry parlance) was very lucrative. You could easily earn over $100,000/year along with a generous car allowance and a very hefty expense account with only a bachelor’s degree by being a drug rep. You did have to sell your soul, however. Your job was to go to hospitals, doctor’s offices, etc and give ‘educational lectures’ on the products that you represented. You passed out notepads, pens, prescription pads, coffee mugs, and mentioned the name of the drug as much as possible. Research found that the more you mentioned the name of the drug, the more it got prescribed. Facts about efficacy, side-effects, and cost didn’t really matter. You could take the doctor’s out to dinner, buy them drinks, take them to the golf course, pay their green’s fees, etc.

    Now, all that is gone. When the new rules disallowing a lot of the cushy ‘perks’ the drug reps could offer, the drug reps got fired (or at least took big pay cuts). One of he more disturbing trends I heard was that many companies were only hiring young, female drug reps, regardless of qualifications. One company, during a documentary, stated that they were only hiring drug reps who were thin, attractive, and had been college cheerleaders because they found that they resulted in the largest increase in sales. The drug company recruiter thought this was great because it showed that you didn’t need all that ‘science stuff’ to be a good drug rep. You just needed a good personality and to be a go-getter. That’s what cheerleaders are!

  2. (apologies — previous post got chopped off.)

    I wonder if the ethics considerations apply in the other direction. My doctors (some of them, anyhow) have often said to me, “This drug is available by brand name or by generic. The drug companies claim that the brand name is better. I’ve never seen any hard evidence to support that, but some of my patients have anecdotalaly reported better results with some branded drugs than the generic, and nobody has said the opposite, but that might be just a placebo effect. The branded drug costs $200 and the generic costs $40. Which would you like me to prescribe?”

    If I were the drug company, I don’t think I’d be too happy that my doctor was saying this, especially if I’d paid for his Jaguar. On the other hand, I don’t see how what the doctor says is much different from saying “Stinky Buttburger has taken out TV ads claiming that this branded drug improved his B.O. and the generic didn’t.” If the doctor gives the patient complete information, it’s hard to see how the drug companies would have any complaints.

    I think this is especially true for some drugs, like antidepressants and antivirals, where the biochemical mechanism between disease and cure is poorly understood. Doctors sometimes have to just try Drug 1 to see if it works, and if it doesn’t, try Drug 2 and then Drug 3. Under these circumstances, treating a branded and a generic as a different drug makes some sense.

    Agree? Same answer if the doctor says, “The drug company is giving me a lot of gifts and perks to encourage me to prescribe the branded drugs. I’ve taken the coffee mugs and the trips to Biarritz, because they came with no strings attached, but I’m still exercising independent professional judgment and I don’t think there’s any difference.” Has the doctor been unethical? If so, to whom?

  3. I think it’s funny when I get a script for a specific drug and take it to the pharmacy, the pharmacist asks me if I’d like the generic instead, thus negating the doctor’s push for a branded drug.

    I’ve also seen it where the doctor writes a brand name and also writes “Generic OK”.

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