For years, people have been asking, what is implied, and what delivered, in the handshake between pharmaceutical companies and the doctors who conduct their research, speak at their luncheons, or serve on their boards?

Can physicians, even those with grand accomplishments, remain immune from the nagging pull of a gift relationship?

Last week a controversy erupted with this issue the flash point. Writing in Slate.com, authors Jeanne Lenzer and Shannon Brownlee accused the award-winning radio program, The Infinite Mind, of not disclosing that panelists on "Prozac Nation: Revisited," accepted Eli Lilly consulting fees. The subtitle, “Are doctors shilling for drug companies on public radio?” was the billboard for their contention: “Some experts who appear independent are, in fact, serving as stealth marketers for the drug and biotech industries, and reporters either don't know about their sources' conflicts of interests, or they fail to disclose them to the public.”

The show included Dr. Andrew Leuchter, Director of the Laboratory of Brain, Behavior, and Pharmacology at UCLA, Dr. Nada Stotland, president of the American Psychiatric Association, and Peter Pitts, former FDA official. Even Dr. Fred Goodwin, the show’s distinguished anchor known for his gentle manner, soft-spoken questions, and his distinguished career including head of NIMH, came under fire for fiscal relationships.

Not so quick, responded producer Bill Lichtenstein. In a letter sent to media watchdog Romanesko, Lichtenstein reacted as if pharma's marketing practices were tolerable because they were ubiquitous. Lichtenstein did apologize for not knowing that Pitts works for a public relations company whose clients include pharma. But he vigorously defended his reporting practices, saying:



Pharmaceutical companies fund the lion's share of research being conducted today. There are strict ethical codes and laws governing the use of such funds. Journalists covering this industry know that, and routinely disclose only those ties that are likely to raise serious questions about a researcher's neutrality.

Lichtenstein, a respected journalist, did not pause to examine the merits of his critics. Nor did he ponder whether he might have succumbed to the cultural norm assuming symbiosis between research and practitioners. After he explained the firewall between his show's content and its supporters, he turned the tables on Lenzer and Brownlee. He asked if they were journalists scorned because their pitch for an on-air rebuttal was rejected.

His answer confirmed what critics fear. Some aspects of medicine have become indistinguishable from the marketing interests of drug companies. For more than a decade, people have been pointing to dummy foundations housed in academic centers, research findings manipulated or withheld from regulators or the public, sumptuous meals and generous honoraria offered to doctors, and the failures of medical education to erect barriers to pharma. Melody Petersen's new book, Our Daily Meds is one of the recent exposes documenting how the pharmaceutical industry stampedes interest by blitzing journals with ghost written articles under the names of prominent academics. To promote Zoloft, a marketing plan included 85 different articles written in this fashion and targeted to different audiences. A law-suit eventually uncovered them.

Had the guests on The Infinite Mind disclosed their connections to Eli Lilly, would it have mattered? As long as the relationship remains robust, and it certainly appeared to be that at last week’s meeting of the American Psychiatric Association, does disclosure constitute more than a ritualized sanction of a porous wall between marketing and medicine?

Business as usual

The APA convention in Washington, D.C. did not suffer for lack of disclosure. In the official program panelists identified their competing interests, specifying how they received compensation and for what – speakers bureau, stock, grant or research support. The number of participants without competing interests was five times those receiving honoraria. But anybody who went to an industry-sponsored symposium dined on the message along with salad and salmon, while earning continuing medical education credits.

In this way, hundreds of practicing psychiatrists, residents and students, enjoyed their breakfasts, lunches and dinners. Meanwhile they heard about research and treatment from people who fully disclosed their connection to the sponsors. Two of the five speakers in AstraZeneca’s dinner symposium about recovery in schizophrenia disclosed they were consultants or speakers for pharma. Four of the participants in Sunday’s lunch, with Bristol-Myers Squibb/ Otsuka America Pharmaceuticals disclosed 28 different relationships with pharmaceutical companies, while addressing the pharmacological management of children and adolescents with autism, bipolar, early-onset schizophrenia and disruptive behavior disorders. And a new malady pointing to a burgeoning revenue stream -- too much or too little arousal affecting sleep -- was discussed over two breakfast meetings with an educational grant from Takeda. Only one of the four speakers claimed no competing interest.

Disclosure versus influence

Does the focus on disclosure divert attention from access, influence and bias? Conventional hiring practices discourage nepotism, professional athletes are barred from betting parlors, and judges recuse themselves when their experience could affect an outcome. If it is understood that loyalties can affect judgment, it is hard to understand why some doctors consider themselves immune. Or how those still in the midst of professional training acquire a healthy skepticism when exposed to as many as 70 drug company lunches in one year, as were the psychiatric residents in one Canadian program.

In the mid 1980s The New England Journal of Medicine initiated a policy requiring authors to disclose “financial ties with companies that make the products under study.” In an editorial discussing the explosion of such relationships throughout medicine, former editor Dr. Marcia Angel described how difficult it was to find a psychiatrist without financial ties to companies making antidepressants to write an editorial about depression. In another instance she described authors of an article whose financial connections to Bristol-Myers Squibb were so complex that the NEJM was forced to note, “the large number of authors and their varied and extensive financial associations with relevant companies make a detailed listing here impractical.” They summarized the disclosures:



all but 1 . . . of the 12 principal authors have had financial associations with Bristol-Myers Squibb — which also sponsored the study — and, in most cases, with many other companies producing psychoactive pharmaceutical agents. The associations include consultancies, receipt of research grants and honorariums, and participation on advisory boards. Of the 17 other authors, 2 are employees of Bristol-Myers Squibb, 5 . . . have no relevant additional financial ties, and the others have a variety of associations similar to those just mentioned.

Everybody's doin' it

Dr. Adriane Fugh-Berman, director of PharmedOut.org, agrees that disclosure only skims the surface. She calls for an end to pharmaceutical funding for all education (medical school and continuing education conferences). Her organization is joined by a handful of others, including the American Medical Students Association which produced a guide to “pharma-free” meetings. No Free Lunch, also dedicated to ending pharma gifts, was easy to overlook on the margin of the APA exhibition gallery. It was, however, located next to the food court where one could purchase hot dogs and soda. It’s unclear if this was deliberate or just ironical.

How does this affect what practitioners actually do when they treat patients or when they interpret data? Dr. Mark Zimmerman, director of outpatient psychiatry at Rhode Island Hospital, said last week that that diagnosing bipolar disorder in children might be “reinforced by the marketing message of pharmaceutical companies to physicians." It is worth noting that one session at the psychiatry convention asked whether bipolar disorder in children might be over diagnosed.

Some deny that a financial relationship alters judgment. They point to a history of professions reforming themselves and claim this can prevent serving two masters. Others are dubious. Psychiatrist Dr. Daniel Carlat regularly blogs about the unholy alliance. Now Congress is holding hearings about pharma’s reach. As the psychopharmacological revolution offers the promise of treatment for many, it will be unfortunate if the story is sidelined to questions about integrity and credibility, as it was with The Infinite Mind.