I’ve been looking at the Carlat Psychiatry Blog which makes for a very refreshing read. Dr Daniel Carlat is a psychiatrist with a special interest in psychopharmacology and is an assistant clinical professor at Tufts University. Carlat was disillusioned with the world of pharmaceutical sponsored talks and medical education and decided to break away from this scene. He started up his own industry-free continuing education newsletter – the Carlat Psychiatry Report. Last year he started up the Carlat Psychiatry Blog, a blog in which he voices strong opinions on the influence of Big Pharma in psychiatry. In his blog recently, Carlat comments on the investigation into APA funding by congress. It turns out that Carlat was already recruited by the APA to investigate this internally and obviously isn’t allowed to comment on the contents of the internal investigation.
Why is Carlat’s blog refreshing? I think that its healthy for psychiatry to have a critical voice. After all, isn’t this what science is about? Isn’t science about the search for a deeper truth which means trying to knock down hypotheses if they don’t hold up in the light of evidence. Carlat’s blog is in my opinion about questioning those parts of practice in the real world which might obscure this process of reaching this truth. Furthermore this occurs because of a conflict between the culture of science and the culture of business.
The essence of the conflict between the science culture and the ‘commercial culture’ is as follows. Let’s suppose that a talk is being given on depression. The talk is given by Doctor A, and is sponsored by Pharmaceutical Company B which produces antidepressant C. During the talk Doctor A presents evidence on drug C’s effect, using papers (provided by Pharmaceutical Company B) to a group of doctors. Suppose there are 20 studies that have been performed on drug C. Many arguments would run along the lines that not all of the study data will be presented to the doctors and that it would be biased. I would argue that this is an inherent assumption and it occurs for a very simple reason – the attribution of intentionality.
If a company has data on 20 studies for the drug, why not just present this all, so that people can judge the data for themselves. This is where an implicit assumption about the actions of companies existing in a commercial environment enters the picture. Pharmaceutical company B will have shareholders, and indeed has responsibility to these shareholders. The assumption is that the shareholders will be looking solely for return on investments – dividends or an increase in share price – which in turn would be brought about by amongst other things an increase in the company’s profitability. So then the argument runs that the company would be looking to make more money.
Now if we return to the presentation, it can be argued that the company would be interested in sponsoring the event to increase the number of doctors prescribing, thereby increasing sales, profitability and ultimately making more money for the company. (There are many other reasons that a company may sponsor the presentation however). If the company wants more doctors to prescribe, then it can be further argued that they would want to provide the best possible image for the drug – one of the basic principles of branding.
Returning to the 20 trials. Suppose that 10 showed good results and 10 showed bad results. If we applied simple marketing principles – showing the 10 good trials and ignoring the 10 bad trials would be expected to show a better image for the drug. However, missing the 10 drug trials with negative results means that not all of the available evidence is being weighed up. In effect, the ability to challenge the hypothesis of the drug’s efficacy is being suppressed as a result of marketing principles. A nice image which should be more profitable is coming at the cost of science’s ‘warts and all’ image.
The same argument can be applied whenever there is a conflict of interest. Suppose that a research group has spent 20 years pushing a certain theory. Its entirely possible that this group might not want to publish a study with negative results or may choose to write a review of favourable papers. They are usually balanced by other groups pushing competing theories. In this sense, the pharmaceutical companies also compete with each other for market share and head-to-head studies of drugs provide an equivalent arena for testing competing theories of drug efficacy.
However compared to the academic research group, the commercial interests of pharmaceutical companies produce an immediate set of additional assumptions (outlined above) which must be countered in research studies or presentations. This in turn relates to the cultural context of business activities.
The above are arguments. The specifics must be analysed in each situation – for each company, drug and location. This is why Carlat’s blog is so necessary. It gives another opportunity for debate and although this isn’t good for branding, it is good for science.
However, there are two further considerations. Firstly, the debate should be brought with caution. The caution is that less informed readers may mistake a strong viewpoint for a debunking of a medication and this may cause them to stop this medication. Secondly, the objectives in the debate must be clear. For instance, suppose all spin was removed. Does the spin on a drug affect a patient’s perceptions and partially their psychological response to the medication? Would the inability to engage in marketing practices for a drug lead to the demise of a company which has further potentially life-saving treatments in the pipeline?
Carlat’s blog provides a view which challenges others. This is invaluable. In the Hegelian Dialect it is suggested that society moves forwards by a synthesis resulting from the conflict between thesis and antithesis and so we can see how Carlat’s challenges may help to move society forwards.
The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.