Joanna Moncrieff, 27 June 2006
 The use of psychiatric drugs has rocketed over recent years.
Prescriptions of antidepressants, for example, rose by 253% in the ten
years up to 2003 (NICE, 2004). In the United States antidepressants are
among the top selling classes of prescription drug, with
antipsychotics, anti-anxiety agents and stimulants all also ranking
highly and/or showing rapidly increasing sales. The pharmaceutical
industry has had a major role in creating this situation. Back at the
beginning of the era of modern psychopharmacology, industry campaigns
helped to establish the use of chlorpromazine (the first neuroleptic or
antipsyhotic drug) and antidepressant drugs. More recently commercially
funded publicity campaigns have fueled rises in psychotropic drug use.
This activity has lead to the pharmaceutical companies being among the
most successful companies in the world, their profits far outstripping
other commercial sectors.
Marketing drugs
The amount of money lavished on marketing to psychiatrists is
epitomised by the 7th World Congress of Biological Psychiatry held in
2001. Drug companies constructed elaborate installations to attract
delegates’ attention, including an artificial garden (Janssen-Cilag), a
running stream (Lundbeck), a 40-foot rotating tower (Novartis) and a
tent with costumed women offering fortune telling (Organon). At a local
level, drug companies lavish free meals and gifts on doctors and
increasingly other professionals too. The American Psychiatric
Association is said to derive 30% of its annual income from drug
company sources (Pfeiffer, 2001).
It has repeatedly been shown that doctors
prescribing practices are adversely influenced by interaction with
industry representatives and attendance at drug company sponsored
events.
Marketing disorders
Drug companies are increasingly marketing disorders themselves. Long
before a drug is launched disease awareness campaigns are conducted to
"create dissatisfaction in the market", "establish a need" and "create
a desire," according to a recent issue of a pharmaceutical industry
trade journal (Pharmaceutical Marketing, 2002). "Product champions" and
"opinion leaders" are recruited from among the academic community to
endorse the campaign and author articles in scientific journals and
patient groups are supported or even created.
Social Anxiety Disorder (SAD) campaigns
provide an example. Prior to the campaigns SAD was an uncommon
diagnosis for which drug treatment was not generally felt to be
helpful. Company sponsored research claimed that it was more common
than previously thought. In the United States campaign, Cohn and Wolfe,
a public relations agency, employed by the drug company then known as
SmithKline, manufacturers of Paxil (paroxetine, or Seroxat in the UK),
hired academic psychiatrists and celebrity patients and saturated the
media with items about the condition. An apparent patient support
group, the Social Anxiety Disorder Coalition was set up, operating out
of the offices of Cohn and Wolfe, which disappeared at the end of the
campaign. A few months later, SmithKline launched advertisements for
Paxil as a treatment for SAD and by the end of the year sales had risen
so much that it had become the second best selling antidepressant drug
in the United States (Mother Jones, 2002).
Similar industry funded campaigns have concerned
Attention Deficit Hyperactivity Disorder (ADHD), Generalised Anxiety
Disorder, Panic Disorder, Post Traumatic Stress Disorder, Obsessive
Compulsive Disorder and Premenstrual Dysphoric Disorder and,
incredibly, "Compulsive buying disorder"!
The industry has also funded campaigns run by
professional medical institutions such as the Defeat Depression
Campaign conducted in the United Kingdom in the early 1990s (part
funded by Eli Lily, makers of Prozac). This campaign aimed to increase
the diagnosis of depression. Campaign literature suggested that up to a
third of the general population might experience depression at some
point in their lives, that 20% of General Practice attendees might have
some symptoms of depression and that up to half of these required
treatment. The campaign was also concerned to reduce fear of addiction
to antidepressants, even though it has now been recognized that they do
cause discontinuation reactions. Subsequently, levels of prescribing of
antidepressants have increased so dramatically that there is now
concern, even in mainstream psychiatry, that they are being
over-prescribed.
Concepts of psychosis have also been extended with
the popularity of notions such as "early intervention" and preventive
treatment. The manufacturers of the new atypical antipsychotic drugs,
which have been enormously profitable, have funded conferences, journal
supplements and preventive treatment trials. These trials involve
starting young people, judged to be at "high risk" of developing
psychosis, on low dose antipsychotic drugs. Even the most optimistic
estimates suggest that this strategy would mean many young people being
started on long-term antipsychotic treatment who would never actually
become psychotic. The emphasis that is placed on these ideas also helps
to lower thresholds for prescribing antipsychotic drugs generally and
makes it more difficult to avoid long-term drug treatment, even though
we know that at least some people with psychosis do not benefit from it.
Research
Drug companies increasingly control all aspects of drug research from
the design and implementation of a study to the analysis and
publication of data. An high proportion of papers, over half in a
recent study (Healy & Cattel, 2003), are written by commercial
medical writing agencies employed by drug companies, a process known as
"ghost writing". Links between academic doctors and the industry also
include payment for speaking at conferences, consultancy fees, payment
for sitting on boards, and holding equity in a company. In 2000 the New
England Journal of Medicine did not have space to print all the
financial interests of the authors of a paper on the antidepressant
nefazadone and had great difficulty in identifying an academic
psychiatrist to write an editorial on the subject who did not have
financial ties with companies that make antidepressants.
Drug trials in psychiatry may be particularly
susceptible to vested interests. Several authors have described the
numerous methodological devices that can distort results, including use
of questionable definitions of outcome, masking unfavorable side
effects, withholding unfavourable results and masking sponsorship.
Recent publications have demonstrated that non publication of negative
findings has lead to over-estimates of efficacy of antidepressants in
children (Jureidini et al, 2004) and adults (Kirsch et al, 2002).
Impact on mental health care
The current situation in which drugs so dominate psychiatric care does
not serve patients’ interests well. Drugs are frequently used where
they have not been shown to be effective. Other therapeutic activities
have been run down. A report by the Sainsbury Center found that 40% of
inpatients in the United Kingdom had no social or recreational
activities available to them and that occupational therapy and
psychology services for inpatients were very limited. Industry funded
research also helps to reinforce recommendations that psychiatric drugs
need to be taken long-term. In contrast, methodological problems with
the research evidence upon which such recommendations are based, such
as the effects of drug discontinuation, have received little attention
(Moncrieff, in press). There is also little research into ways of
withdrawing patients safely from psychotropic drugs.
The pharmaceutical industry has also played down the risks associated
with psychiatric drugs. Eminent psychiatrists have claimed that drug
companies attempted to impede publication of the adverse effects of
Halcion and sulpiride, for example. Recently, evidence has emerged that
drug companies failed to publish data on adverse effects in trials of
SSRIs including suicidal behaviour (Whittington et al, 2004). Also
literature sponsored by companies producing atypical antipsychotics
appears to play down the recognized risk of developing diabetes with
some of these drugs (Dinan, 2004).
Biological psychiatry has always been contested. Although it now
seems predominant, social or psychologically based approaches remain
popular with patients and many professionals. The pharmaceutical
industry helps to promote a biological approach to the understanding of
human suffering and its huge financial power can be seen as unfairly
tipping the scales. This impoverishes mental health care since
challenges to the hegemony of biological psychiatry provide an
important incentive to the development of innovative and patient
centered services.
Conclusions
The activities of pharmaceutical companies have helped to create a
situation whereby psychiatric drugs are prescribed numerously, often
for long periods, to the detriment of other approaches and despite
emerging doubts about their efficacy in certain situations. The risks
of drug treatment have also sometimes been minimized. However there is
increasing wariness and criticism of the relationship between medicine
and the pharmaceutical industry. Medical journals such as the British
Medical Journal have published several exposés and organizations have
sprung up which monitor the industry’s activities and campaign to
reduce its influence over healthcare (Box 1). The tide may be turning,
but there is a long way to go.
Further Information
Alliance for Human Research Protection, US (ahrp.org)
Adverse Psychiatric Reactions Information Link, UK (april.org)
Corpwatch, US (corpwatch.org)
Health Which, UK (which.co.uk)
Healthy Skepticism, Australia (healthyskepticism.com)
Public Citizen, United States (citizen.org)
Social Audit, UK (socialaudit.org.uk)
Joanna Moncrieff is Senior Lecturer, Department of Mental Health Sciences,
University College London and Honorary Consultant Psychiatrist,
North East London Mental Health Trust. email j.moncrieff AT ucl.ac.uk
Acknowledgements
This paper summarises and updates a Maudsley Discussion Paper, "Is
Psychiatry for Sale?" where more references can be found. It is
available from the Institute of Psychiatry and at
www.critpsynet.freeuk.com/pharmaceuticalindustry.htm
References
Dinan TG (Ed) (2004) Schizophrenia and diabetes 2003: an expert
consensus meeting. British Journal of Psychiatry 184, Supplement 47.
Healy D & Cattell D (2003) The interface between authorship,
industry and science in the domain of therapeutics. British Journal of
Psychiatry, 183, 22-27.
Jureidini JN, Doecke CJ, Mansfield PR, Haby MM, Menkes DB, Tonkin AI
(2004) Efficacy and safety of antidepressants for children and
adolescents. BMJ 328:879-883.
Kirsch I, Moore TJ, Scoboria A, Nicholls SS (2002) The emperors new
drugs: an analyisis of antidepressant medication data submitted to the
U.S. Food and Drug Administration. Prevention and Treatment 5, www.journals.apa.org/prevention/volume5/pre0050023a.html.
Moncrieff J (in press) Does antipsychotic withdrawal provoke psychosis?
A review of the literature on rapid onset psychosis (supersensitivity
psychosis) and withdrawal related relapse. Acta Psychiatrica
Scandinavica.
Mother Jones (2002) Disorders made to order. Mother Jones magazine, July/August 2002. www.motherjones.com
NICE (National Institute for Clinical Excellence) (2004) Depression:
management of depression in primary and secondary care. Clinical
practice guideline No 23, London: NICE.
Pharmaceutical Marketing (2002) Practical Guides: Medical Education parts I & II. Pharmaceutical Marketing, 2002. www.pmlive.com
Pfeiffer MB (2001, June 10th) Drug marketing is widespread. Poughkeepsie Journal, pA2.
Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrave A, Boddington
E (2004) Selective serotonin re-uptake inhibitors in childhood
depression: Systematic review of published versus unpublished data.
Lancet 363, 1341-1345.
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