It was 95 degrees with 99 percent humidity. The Gulf had the biggest oil spill in US history. And attendees to last week’s American Psychiatric Convention (APA) annual meeting in New Orleans had to brave 200 protestors chanting "no drugging kids for money" and "no conflicts of interest" to get into the convention hall.
Since 2008 when Congress investigated some APA psychiatrists for alleged drug industry conflicts of interest, more light has shone between the two groups, historically almost indistinguishable.
Participants at this year’s meeting, estimated at 14,000, saw conflict of interest slides before presentations and in their 240-page program book, fewer drug industry funded classes and entertainment and no gifts or free meals at the 5-day event.
"They used to wine us and dine us," said one participant, a veteran of decades of annual meetings, ruefully.
"An SSRI maker flew my entire group to a Caribbean island," remembered a doctor from the East coast who did not want to be identified. Anymore.
But polarizing figures were still present. Sitting next to outgoing APA president Alan F. Schatzberg, MD, even as protestors chanted outside, was Charles Nemeroff, MD, former psychiatry chairman at Emory University who was investigated by Congress for unreported GlaxoSmithKline income and left his post in disgrace. Nemeroff was signing the Textbook of Psychopharmacology which he co-edited with Schatzberg, also investigated by Congress. Schatzberg, psychiatry chairman at Stanford, consults to seven drug companies, owns stock and patents with others and is on Sanofi-Aventis’ Speakers Bureau according to the meeting’s Daily Bulletin.
Heading a symposium about schizophrenia was S. Charles Schulz, MD, psychiatry chairman at the University of Minnesota who was investigated for financial links to AstraZeneca believed to alter his scientific conclusions.
Presenting a poster about the benefits of long acting risperidone was Wayne MacFadden, MD, AstraZeneca’s US medical director for Seroquel until questions about his alleged sexual affairs with women doing research on the drug arose.
And a paper presented about attention deficit hyperactivity disorder (ADHD) was co-written by Harvard’s Joseph Biederman, MD, also investigated by Congress for drug industry financial links and considered the father of the pediatric bipolar disorder craze.
Despite the thaw in drug industry bennies, exhibition displays were still pretty gee-whiz with Cymbalta, Seroquel XR, Abilify, Lunesta and Pristiq the most prominent. (A rep struggled to explain to a group from Columbia that Pristiq was not, repeat not, just a more expensive Effexor.) ADHD drugs was also big. "Let’s be as brave as the people we serve" said a Shire display, showing a patient’s giant, valiant face; another of its displays reconstructed a children’s bedroom to sell INTUNIV.
But where take-one signs once existed, signs now warned health care providers they may be governed by no gift policies. And whereas glad-handing reps were still eager to answer questions — once they scanned badges for marketing data — they referred pharmacodynamic and patient care questions to an "information booth" where a real doctor, looking less pleasant, stood.
Nor was there a star of the show. The Next Big Thing was not a new drug at all but adjunctive therapy also known as adding existing drugs to existing drugs because they don’t work right. Throwing good drugs after bad, popularized with the antipsychotic Abilify, has only been enhanced by a study in the January JAMA that found antidepressants don’t work for mild depression at all. Antipsychotics are also being "enhanced" by adding drugs to offset weight gain and lethargic side effects.
No wonder panelists at a forum called "Is a Game Changing Psychotropic Too Much to Expect?" assailed drug industry for issuing "me too" drugs and "seat of the pants" drug combinations, calling the industry nothing but a "marketing organization."
No wonder a Canadian physician castigated the FDA’s Jing Zhang for approving drugs for "competitive reasons" not patient health in a symposium about comparative drug effectiveness. "In a recent transcript on your web site, Dr. Laughren [FDA director of psychiatry products] clutches at studies to try to approve a new drug on behalf of industry," he charged. "FDA’s non-inferiority studies in which a drug can be less effective that an existing one and only beat placebo, present the ‘patient risk’ of a drug not working," he said.
But elsewhere drugs were given a better spin.
Ann Childress, MD, gave a veritable commercial for the ADHD drug Vyvanse, manufactured by Shire on whose Speaker’s Bureau she serves. And the Wyeth funded C. Neill Epperson, MD, appearing with Wyeth Speakers Bureau member Claudio Soares, MD, actually told a clinician in the audience not to trust a pharmacist for a hormone preparation but to use drug industry preparations in a symposium called "Mood, Memory and Myths: What Really Happens at Menopause." Biodentical hormones, compounded by pharmacists, have been a revenue threat for Wyeth’s menopause drugs. (The seminar’s pro hormone therapy message crumbled when breast cancer patients in the audience discussed their "chemo" and "tamoxifen brain.")
If there were a take home message at the APA meeting about the blizzard of ADHD, bipolar and personality disorders threatening adults and children, it was don’t wait. These dangerous conditions, no different from cancer and diabetes, won’t go away.
Thanks to genetic advancements, psychiatric disease risks can now be detected and treated before symptoms surface, said presenters, fostering early treatment paradigms that are pretty Brave New World: People being told they have a disease they can’t feel that needs immediate and lifelong treatment at hundreds of dollars a month or their health will suffer. Run that past me again? The National Institute on Drug Abuse is even working on vaccines to treat the specific genetic risks in opioid addicts. Good luck with that.
Not everyone agreed about early treatment. The very fact that bipolar disorder is a lifelong disease is reason to wait until you are sure said Mark Zimmerman, MD director of outpatient psychiatry at Rhode Island Hospital whose research, published in the June Journal of Nervous and Mental Disease, finds a link between unconfirmed, overdiagnosed cases of bipolar disorder and the receipt of disability payments.
Not everyone agreed about multidrug combinations commonly called polypharmacy either. In between industry "research" in poster sessions extolling Seroquel, Vyvanse, Saphris, Geodon, Risperdal and Zyprexa was a study at Maimonides Medical Center in Brooklyn "Evaluating Antipsychotic Polypharmacy Regimens for Patients with Chronic Mental Illness."
When 24 patients on polypharmacy combinations of Seroquel, Zyprexa and other antipsychotics were reduced to only one drug — monotherapy — there was no worsening of symptoms or increased hospitalizations in 23. Not only did patients not deteriorate, their waist circumferences and triglycerides improved, say the researchers as drug interactions, side effects and, of course, cost of treatment declined.
"These are interesting data," said a young female psychiatrist viewing the poster. "Normally clinicians are afraid to take such patients off polypharmacy."
So is the drug industry.