Can Science withstand Capitalism?

Today I want to write about the connection between psychiatry, pharmaceutical research, and the drug industry. This is by no means a new issue – in fact, it’s been written about for years – but I came across a few discussions of it today and decided to take that as my cue to devote some space to this issue.

Of course there are links between psychiatric practitioners, researchers, and the drug industry. These three branches supposedly collaborate in the provision of adequate and effective drugs to the patients who need them. Researchers use their expertise on the brain to develop potent chemical agents to solve certain pathologies of the neural network. These drugs are manufactured and tested by the pharmaceutical companies, whose infrastructure helps deliver the drugs to the patient. But this distribution is mediated by the psychiatrist, whose clinical expertise and detailed knowledge of a drug’s effect is able to determine for which patient the drug is right. Ideally, each branch possesses a body of knowledge that is based on objective medical science, and is motivated in its pursuits by the ideal of helping a sick patient.

In reality, however, these links are much more complex. The bodies of knowledge involved are by no means objective, and the ideal of helping sick patients is pushed to the background by more immediate rewards.

The problem is that prescription is not guided solely by a doctor’s ‘neutral’ assessment of your symptoms; a doctor’s decision for a particular treatment plan emerges not just from clinical experience. It is driven also by the advertising for particular drugs that is directed at the doctor, and – more importantly – by the incentives a doctor receives from drug companies to prescribe particular drugs to his or her patients. Doctors get paid to prescribe certain medications, or to direct their patients to clinical trials testing a particular drug (which, of course, is another form of advertising). This simply leads to a bias that has nothing to do with clinical experience, and everything to do with money. There is an incentive in prescription for doctors that has nothing to do with actual efficacy.

The result? Doctors themselves often claim that they remain unmoved by the advertising directed at them by drug companies; they claim that their medical expertise withstands the lure of a marketing spin. Yet data speaks otherwise. Articles everywhere (this one, for instance) cite the New York Times’ analysis of data from Minnesota, which pointed out that doctors who received $5,000 or more from psychopharmaceutical companies were three times more likely to prescribe their drugs than doctors who had received no such incentives.

The problem is that in the end, the pharmaceutical industry is just that – an industry. Sure, their product may cure a debilitating disease, but ultimately, the industry’s goal is to sell its product and make money. They engage in the same strategies that any other product manufacturer would employ – advertising, marketing, PR. In other words: create news, promote positive stories about your product, encourage people to sell your product for you, and encourage consumers to ask for that product. The pharmaceutical companies do this in a variety of ways.

Advertising is a big deal. We’re all bombarded with commercials for new drugs on a daily basis. These are directed at doctors as well as consumers – that is, the patients. Ads for psychopharmaceuticals don’t just raise awareness for their product. They don’t just proclaim its miraculous effects. If you look closely, the ads for psychopharmaceuticals are not trying to sell you a pill; they’re trying to sell you a disease. These ads define an illness: they describe a set of symptoms and emphasize their debilitating nature, showing an individual in obvious distress. But, the ad then tells you, full of hope, there is a solution.

Exactly. Their drug.

The point is that these psychopharmaceutical advertisements change the definition of illness, usually by broadening its applicability. They alter our perception of our own experiences, and encourage us to see what used to be considered normal variation of the human condition as pathology. They create, in the words of Stefan Ecks, a “monoculture of happiness” (Ecks 2005:241), in which any sign of sadness is pathologized. This helps a company sell: the more often an illness is identified, the more often a drug linked to that illness will be prescribed. This is why the incredible rise in the incidence of depression in the past decades coincides with the introduction of antidepressant drugs like Prozac, and, as the New York Times argues, the increasing number of children diagnosed with pediatric bipolar disorder coincides with the introduction of new atypical antidepressants. This works on doctors, but on patients, too. The direct-to-consumer advertising encourages us all to wonder if Cymbalta may be right for us. After all, we all feel sad once in a while.

Another, very important, form of advertising for psychopharmaceutical companies consists of the funding of research, such as clinical trials. Abstractly speaking, this is commendable. More research is always good, and it is indeed sold as ultimately benefiting the patient, who will receive a drug whose efficacy and side-effects have been extensively tested. But the same problem emerges, because money and profits are involved: the point of these clinical trials is not to present ‘objective’ results. It is a form of marketing: the aim is to produce ‘scientific’ backing for the promotion of a particular drug. What this means: negative results are often ignored, while positive ones are often hyped up beyond all statistical validity and presented to medical professionals. Here, too, clinicians are paid to get involved. They are recruited to present the outcome of studies at conferences, or to ghost-write articles touting a drug’s miraculous efficacy. David Healy has written and spoken about this. At a lecture held at UCSD last year, he showed slides of pre-fab articles written by drug companies, that he was asked to claim authorship over in return for payment. For the drug company, such an agreement means scientific legitimacy for their study, and thus for their drug. For the psychiatrist, having such an article under one’s list of publications not only means financial boons, but also a reputation as a leader in the field. But the point, once again, is that all objectivity is gone. One might question the existence of objectivity in (biomedical) science altogether, and I usually do, but this is bias at a new level.

And in a sense, there’s nothing wrong with all this. The pharmaceutical industry is a manufacturer of products trying make money, just like any other company would do. It’s understandable, from a very detached point of view, that they do what they can to market their product. But what complicates matters is that in other cases – for those other manufacturers, of cosmetics, or macaroni, or air fresheners – their product is not something whose necessity for consumers is a matter of life or death (even if it’s symbolic death – the loss of ability or productivity). Advertising and marketing campaigns aren’t really fair (or ethical) when the need for a product is independent of a consumer’s buying power, susceptibility to advertising, and so on – and when unnecessary use of the product can be hazardous to one’s health. There is more involved with drugs than simple supply and demand.

All this is true for all areas of medicine, and all pharmaceutical companies are guilty of it. But it seems worse than normal in the case of psychiatry. Perhaps this is because psychiatric disorders are so much more elusive than any other disease. There are no simple, conclusive tests, and so the freedom of definition and diagnosis is much greater. Disorders like depression are diagnosed on the basis of observable symptoms, and rely very strongly on a doctor’s assessment of their impingement on normal functionality. There is a lot of room for interpretation. There is, in other words, much more space for the marketing and advertising of psychopharmaceuticals than there is for other drugs. An article on consumerist.com suggests, moreover, that psychiatrists are more susceptible to the financial incentives provided by drug companies because their base salary is generally lower than that of any other specialists.

So what do we do? Is there a solution here? Doctors are required to declare their income from pharmaceutical companies. Hypothetically that might work – if anything, to raise some awareness even on the part of the doctor that she’s being enticed to do certain things because of money. But other than that… does ‘transparency’ of financial connections and incentives really do anything? Even that aspect of awareness is questionable, I think. As I’ve mentioned, a lot of doctors will maintain that their medical objectivity is strong enough to withstand the force of financial incentives. The actual flow of money needs to be regulated in some way. I’m not suggesting that I have any ideas on how to do this, but something should be done. Perhaps limits on the amount of money doctors can receive from drug companies would work? Or, as is done in Europe, ban direct-to-consumer advertising of prescription drugs altogether. It makes no sense anyway. The government regulates the distribution of these drugs through prescription, yet entices everyone with it through advertising. Isn’t that unfair?