The Going Rate on Shrinks

It was last summer in Berlin when I first encountered pharmaceutical funhouses. I was one of 4,000 attendees at the 7th World Congress of Biological Psychiatry. Until about a decade ago, pharmaceutical companies passed out pens or notepads with their companies' logos at such events, and most speakers presented data and opinions based upon their true scientific beliefs.

That all changed when Big Pharma took over. At the congress, I counted 15 major displays on the way to the lunch area, including an artificial garden (Janssen-Cilag), a brook running over stones (Lundbeck), and a 40-foot rotating tower (Novartis). Almost all offered free food and drink, T-shirts, or other inducements designed to get psychiatrists to pause so that an army of smiling sales representatives could give their sales pitch.

Eli Lilly's display included two large, walk-through tunnels set up like funhouses. One tunnel, labeled "Zyprexa," included a mirrored room with dozens of telephones dangling from the ceiling. Was Lilly trying to convince me that God was calling, telling me to prescribe Zyprexa? The sales representative said no, the phones were meant to illustrate the communication problems common in schizophrenia, which Lilly claims Zyprexa improves. The other funhouse, labeled "Prozac," featured a 10-foot mouselike creature sitting in front of a blank television screen. I asked whether Lilly was recommending Prozac for mice. The representatives said no, the creature was really a depressed man who needed Prozac.

My favorite display, by the Dutch firm Organon, advertised Remeron, an antidepressant. It featured a small, multihued tent with purple doors and the painted head of a genie. Inside, a red-robed young woman with sprinkles in her hair was taking Polaroid pictures, one by one, of psychiatrists who had waited patiently in line for 20 minutes or more. This was no ordinary picture but rather a snapshot of one's aura, taken, as the Organon brochure noted, "with advanced biofeedback equipment." The equipment consisted of two small machines, on which I placed my hands. The result was a picture of my head peering out of a red, orange, and yellow cloud.

According to the brochure, "the aura colors give you information about your appearance, character, talents, and future energy." After taking my picture, the red-robed young woman escorted me to a yellow-robed young woman with even more sprinkles in her hair. "Hi! My name is Amber," she said, and proceeded to interpret the picture of my aura as indicating intelligence and good judgment, although with some hints of skepticism.

I privately asked the Organon sales staff if they thought it wise to associate their product with auras, magic, New Age thinking, and anti-science. They said the decision had been made at "a higher level" but pointed out that the waiting line was an ideal place for engaging psychiatrists in brief, friendly chats about the virtues of Remeron.

This is, after all, big business. Antidepressant and antipsychotic drugs are among America's top-selling pharmaceuticals. Last year Prozac and Zyprexa accounted for almost half of Eli Lilly's total sales. Sales of antipsychotic medications have quadrupled in the past four years to more than $4 billion. These drugs are a major reason why the profitability of the 11 pharmaceutical companies in the Fortune 500 "was almost four times greater" than the median for all Fortune 500 companies during the 1990s, according to a report by the Public Citizen Health Research Group.

Not surprisingly, psychiatrists have become a prime target of pharmaceutical companies' marketing, because prescription drugs can't be sold directly to consumers. In the United States, pharmaceutical companies spend an estimated $8,000 to $13,000 per physician per year on marketing.

At professional gatherings, of course, one must offer the attending psychiatrist more than an opportunity to view one's aura. The Berlin Congress offered 136 symposia plus workshops and lectures. Of these, 23 were clearly labeled as being sponsored by pharmaceutical companies; all focused on drugs to treat psychiatric disorders. Several other industry-sponsored talks had no disclosure of the sponsorship.

Each brought in two to four psychiatric experts, whom the sponsoring pharmaceutical company usually gave business-class air tickets, four-star hotel accommodations, and an honorarium, typically $2,000 to $3,000. If the expert organized the symposium, the payments went as high as $5,000, and higher still if the expert presented data very favorable to that company's drug (or at least presented unfavorable data in a very favorable light). One American expert was paid $10,000 last year to fly to Europe to give a single lecture.

Symposia and workshops on subjects not directly concerned with drug prescriptions had little, if any, industry support. The speaker at one such symposium, which was lightly attended, said he "felt like the legitimate act at a burlesque show, included only to keep the cops out."

Honoraria and future invitations are directly dependent on how experts present their data. Emphasizing adverse effects of a drug, for example, may well cost the expert a trip to future congresses. Some of the psychiatric experts sponsored by a pharmaceutical company are also on the company's speakers bureau; many own stock and thus have a direct financial interest in the success of the company's products.

The ultimate targets for this pharmaceutical extravaganza, of course, are the practicing psychiatrists who constitute the vast majority of attendees. Although meeting officials won't provide precise numbers, they acknowledge that pharmaceutical companies had sponsored more than half of the attendees. Sponsorship normally includes coach-class airfare, hotel accommodations, and registration fees as well as special receptions and parties, some literally with dancing girls.

Pharmaceutical companies in many countries can now use computerized pharmacy databases (which delete the names of the patients) to track how many prescriptions any given physician writes for any given drug. So Eli Lilly could sponsor Dr. Smith from Detroit or Manchester, send him to Berlin, and then monitor his prescribing pattern following the congress. If Dr. Smith's prescriptions for Zyprexa and Prozac do not increase sufficiently, a company representative can remind him how well he was treated in Berlin. And besides, isn't he interested in going to Copenhagen next summer?

There is clear evidence that attending conferences such as the Berlin meeting does affect the prescribing practices of physicians. In one U.S. study, 10 physicians were invited by a pharmaceutical company to attend "all-expenses paid" symposia at "popular Sunbelt vacation sites." The company tracked the physicians' prescribing patterns for two drugs, for 22 months before and 17 months after the symposia. Though the physicians had predicted that their attendance would not affect their prescribing practices, their prescriptions for one drug increased 87 percent and for the other, 272 percent. Other studies have shown that attending drug-sponsored education courses affects drug-prescribing practices, even though the physicians deny it. Indeed, if it were otherwise, why would pharmaceutical companies sponsor such activities?

Does any of this really matter? It does, for two reasons. First, patient care suffers when physicians are misled. Psychiatrists trying to evaluate schizophrenia drugs are not told that the expert who minimizes the side effects of Zyprexa receives a $10,000 retainer from Eli Lilly and also owns substantial company stock. Or that the psychiatric expert claiming that Remeron reverses depression more rapidly in suicidal patients receives $75,000 per year from Organon to support his laboratory.

Second, the hoopla adds to the cost of drugs. Payments to aura interpreters and dancing girls are simply passed on to patients. The pharmaceutical company costs for the Berlin congress were at least $10 million. According to a recent report, in 2000 the 11 pharmaceutical firms in the Fortune 500 "devoted nearly three times as much of their revenue to marketing and administrative costs (30 percent of revenue) as to research and development (12 percent of revenue)."

Plainly some changes are in order. Reform should start with medical students. As one observer summarized it in The New England Journal of Medicine: "Medical training should not include acquiring a sense of entitlement to the largesse of drug companies." Pharmaceutical companies should be banned from giving gifts to medical students and residents; the free pizza from the drug representative may seem trivial, but it sets a pattern that rationalizes accepting a free trip to Berlin later on. Practicing psychiatrists should get their continuing education from objective sources, not from drug "detail" (marketing) persons and industry-sponsored talks. Vermont has just made a modest beginning with a law requiring disclosure of all drug-company gifts to doctors valued at more than $25. The profession's ethical standards should prohibit experts who are involved in drug trials or giving talks at symposia from owning stock in pharmaceutical companies. Unfortunately, most of the profession's organizations, such as the American Psychiatric Association, are themselves so indebted to drug companies that they are unlikely to lead reform.

For speakers at symposia such as the Berlin meeting, the solution is simple. Prominently displayed next to the speaker's lectern should be a sign reading: "For this talk, Dr. Smith is being paid $3,500, business-class airfare, and four-star hotel accommodations by Eli Lilly and Company."