APA's annual meeting is one of the largest medical meetings in the United
States and the largest psychiatric meeting in the world. There is something
for everyone at our wonderful meeting, but many have commented to me on the
extraordinary presence of the pharmaceutical industry throughout the
scientific programs and on the exhibit floor.
The U.S. pharmaceutical industry is one of the most profitable industries
in the history of the world, averaging a return of 17 percent on revenue over
the last quarter century. Drug costs have been the most rapidly rising element
in health care spending in recent years. Antidepressant medications rank third
in pharmaceutical sales worldwide, with $13.4 billion in sales last year
alone. This represents 4.2 percent of all pharmaceutical sales globally.
Antipsychotic medications generated $6.5 billion in revenue.
When the profit motive and human good are aligned, it is a"
win-win" situation. Pharmaceutical companies have developed and
brought to market medications that have transformed the lives of millions of
psychiatric patients. The proven effectiveness of antidepressant,
mood-stabilizing, and antipsychotic medications has helped sensitize the
public to the reality of mental illness and taught them that treatment works.
In this way, Big Pharma has helped reduce stigma associated with psychiatric
treatment and with psychiatrists. My comments that follow on the
pharmaceutical industry and its relationship to psychiatry bear this in
The interests of Big Pharma and psychiatry, however, are often not aligned.
The practice of psychiatry and the pharmaceutical industry have different
goals and abide by different ethics. Big Pharma is a business, governed by the
motive of selling products and making money. The profession of psychiatry aims
to provide the highest quality of psychiatric care to persons who suffer from
psychiatric conditions. There is widespread concern of the over-medicalization
of mental disorders and the overuse of medications. Financial incentives and
managed care have contributed to the notion of a "quick fix" by
taking a pill and reducing the emphasis on psychotherapy and psychosocial
treatments. There is much evidence that there is less psychotherapy provided
by psychiatrists than 10 years ago. This is true despite the strong evidence
base that many psychotherapies are effective used alone or in combination with
In my last column, I shared with you my experience, and APA's, in
responding to the antipsychiatry remarks that Tom Cruise made earlier this
summer as he publicized his new movie in a succession of media interviews. One
of the charges against psychiatry that was discussed in the resultant media
coverage is that many patients are being prescribed the wrong drugs or drugs
they don't need. These charges are true, but it is not psychiatry's
fault—it is the fault of the broken health care system that the United
States appears to be willing to endure. As we address these Big Pharma issues,
we must examine the fact that as a profession, we have allowed the
biopsychosocial model to become the bio-bio-bio model. In a time of economic
constraint, a "pill and an appointment" has dominated treatment.
We must work hard to end this situation and get involved in advocacy to reform
our health care system from the bottom up.
Furthermore, continuing medical education opportunities sponsored by
pharmaceutical companies are often biased toward one product or another, and
they are more akin to marketing than CME. APA has strict guidelines for the
industry-sponsored symposia presented at our annual meetings; sanctions are
applied when our rules are broken. Our guidelines have been held up as a
standard for medical meetings in other specialties throughout the country. But
there are many grand rounds, evening dinners, and lectures where such
standards do not prevail.
Direct marketing to consumers also leads to increased demand for
medications and inflates expectations about the benefits of medications. As a
profession, we need to be concerned about advertising and the impact it has on
the over-medicalization of our field. Of course, what is marketed to consumers
are the highest-cost, on-patent products, and the cost of medications is
something rarely considered by prescribing clinicians. When doctors don't
prescribe cheaper but equally effective drugs, it consumes money that could
have been used to provide other psychiatric or medical services.
There are examples of the "ugly" practices that undermine the
credibility of our profession. Drug company representatives will be the first
to say that it is the doctors who request the fancy dinners, cruises, tickets
to athletic events, and so on. But can we really be surprised that several
states have passed laws to force disclosure of these gifts? So-called"
preceptorships" are another example of the "ugly";
that is, drug companies who pay physicians to allow company reps to sit in on
patient sessions allegedly to learn more about care for patients and then
advise the doctor on appropriate prescribing.
Drug company representatives bearing gifts are frequent visitors to
psychiatrists' offices and consulting rooms. We should have the wisdom and
distance to call these gifts what they are—kickbacks and bribes. (For
more thoughts on this topic, see Viewpoints on
page 33.) If we are seen
as mere pill pushers and employees of the pharmaceutical industry, our
credibility as a profession is compromised.
Here are several suggestions for remedies in our relationship with the
As psychiatrists, we should all be grateful for the modern pharmacopia and
the promise of even more improvements in the future. At the same time,
however, we must be very mindful that we cannot accept gratuities in the new
medical marketplace. ▪