Thursday, September 28, 2006

Review of Doughnuts for Doctors

Doughnuts for the Doctors: Moynihan and Cassels on the pimping of antidepressants…

I was very much looking forward to their book, Selling Sickness, as I’ve been favorably impressed with much of Moynihan’s earlier work on disease mongering. The authors discuss depression in a chapter titled Doughnuts for the Doctors, in 18 short pages, which is unfortunately far too brief for the weighty topics tackled within. They point out that physicians are certainly influenced by contacts with drug reps, and that there are a litany of problems with SSRI’s (suicidality, small advantage over placebo, significant side effects such as sexual dysfunction, etc.), but the attention given to these points is unfortunately too brief.

I was more impressed with their description of the American Psychiatric Association’s convention, where the virtual orgy of drug promotion disguised as education (industry-sponsored symposia and those slick looking booths staffed by likely remarkable attractive cheerleaders, er, drug reps) was discussed again too briefly, but in a captivating manner. Loren Mosher, who quit the APA a few years ago in disgust, along with David Healy are discussed in passing. For Healy, especially, this is short shrift.

More interesting was the debate on the prevalence of mental disorders, including depression, which focused on the differing findings of Kessler versus Narrow in their estimates of the aforementioned problems. Certainly, Narrow found a lower prevalence for mental disorders than did Kessler, and the discussion is important and timely for all mental health practitioners and researchers.

My favorite line in the chapter is in the context of the finding that half of people receiving treatment for mental disorders were “either noncases or mild cases.” The authors opine cleverly, “The global obsession with “unmet need” – a notion that is constantly pushed by doctors and drug companies as the justification for aggressive drug marketing – may well be helping to create a strange new phenomenon: ‘met un-need.’” A great point when one considers how much energy (some of it indeed justified) goes into campaigns to get more people into treatment because [insert mental disorder here] is undertreated in the community. The authors then discuss a screening test from our friends at Bristol Myers Squibb which found that 49% of individuals had a “mental disorder." Later research showed, unsurprisingly that this test was a poor assessment of mental health. More (but still not enough) on marketing depression follows after this point.

A little more on the well-tread territory of antidepressant use in children follows, in which their insights are spot-on. What I found more interesting was the discussion of “thought leaders” and their development by the drug industry. Another great quote follows:

“Promising prospects might be singled out by a detailer as a potential thought-leader, and then given some small speaking engagement to test them out. Later, if they’ve proven their worth, they might be paid to speak regularly in small local settings about the latest new drug in the pipeline. With a bit of luck the thought-leader could eventually find themselves on a drug company’s ‘speaker’s bureau’ earning thousands of dollars for making presentations to their international peers about the latest new disease, at high-profile events like the APA congress in New York.”

More good stuff follows on “thought leaders," though yet again I wanted more.

Overall: If I had to assign stars, I’d give this chapter 4 of 5. Great source of references for the interested reader. The writing was solid and interesting, but it just went too quickly from topic to topic. Nonetheless, it is hard to disagree with their implicit conclusions that antidepressants are much more a miracle of marketing than science.

Hopefully time will arise for a brief synopsis of the ADHD chapter as well.

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