Latuda-Palooza: Marketing or Education?

October 2, 2011

In my last blog post, I wrote about an invitation I received to a symposium on Sunovion Pharmaceuticals’ new antipsychotic Latuda.  I was concerned that my attendance might be reported as a “payment” from Sunovion under the requirements of the Physicians Payment Sunshine Act.  I found it a bit unfair that I might be seen as a recipient of “drug money” (and all the assumptions that go along with that) when, in fact, all I wanted to do was learn about a new pharmaceutical agent.

As it turns out, Sunovion confirmed that my participation would NOT be reported (they start reporting to the feds on 1/1/12), so I was free to experience a five-hour Latuda extravaganza yesterday in San Francisco.  I was prepared for a marketing bonanza of epic proportion—a la the Viagra launch scene in “Love And Other Drugs.”  And in some ways, I got what I expected:  two outstanding and engaging speakers (Dr Stephen Stahl of NEI and Dr Jonathan Meyer of UCSD); a charismatic “emcee” (Richard Davis of Arbor Scientia); an interactive “clicker” system which allowed participants to answer questions throughout the session and check our responses in real time; full lunch & breakfast, coffee and snacks; all in a posh downtown hotel.  (No pens or mugs, though.)

The educational program consisted of a plenary lecture by Dr Stahl, followed by workshops in which we broke up into “teams” and participated in three separate activities:  first, a set of computer games (modeled after “Pyramid” and “Wheel Of Fortune”) in which we competed to answer questions about Latuda and earn points for our team; second, a “scavenger hunt” in which we had 5 minutes to find answers from posters describing Latuda’s clinical trials (sample question: “In Study 4 (229), what proportion of subjects withdrew from the Latuda 40 mg/d treatment arm due to lack of efficacy?”); and finally, a series of case studies presented by Dr Meyer which used the interactive clicker system to assess our comfort level in prescribing Latuda for a series of sample patients.  My team came in second place.

I must admit, the format was an incredibly effective way for Sunovion to teach doctors about its newest drug.  It reinforced my existing knowledge—and introduced me to a few new facts—while it was also equally accessible to physicians who had never even heard about Latuda.

Moreover, the information was presented in an unbiased fashion.  Unbiased?, you may ask.  But wasn’t the entire presentation sponsored by Sunovion?  Yes, it was, but in my opinion the symposium achieved its stated goals:  it summarized the existing data on Latuda (although see here for some valid criticism of that data); presented it in a straightforward, effective (and, at times, fun) way; and allowed us doctors to make our own decisions.  (Stahl did hint that the 20-mg dose is being studied for bipolar depression, not an FDA-approved indication, but that’s also publicly available on the clinicaltrials.gov website.)  No one told us to prescribe Latuda; no one said it was better than any other existing antipsychotic; no one taught us how to get insurance companies to cover it; and—in case any “pharmascold” is still wondering—no one promised us any kickbacks for writing prescriptions.

(Note:  I did speak with Dr Stahl personally after his lecture.  I asked him about efforts to identify patient-specific factors that might predict a more favorable response to Latuda than to other antipsychotics.  He spoke about current research in genetic testing, biomarkers, and fMRI to identify responders, but he also admitted that it’s all guesswork at this point.  “I might be entirely wrong,” he admitted, about drug mechanisms and how they correlate to clinical response, and he even remarked “I don’t believe most of what’s in my book.”  A refreshing—and surprising—revelation.)

In all honesty, I’m no more likely to prescribe Latuda today than I was last week.  But I do feel more confident in my knowledge about it.  It is as if I had spent five hours yesterday studying the Latuda clinical trials and the published Prescribing Information, except that I did it in a far more engaging forum.  As I mentioned to a few people (including Mr Davis), if all drug companies were to hold events like this when they launch new agents, rather than letting doctors decipher glossy drug ads in journals or from their drug reps, doctors would be far better educated than they are now when new drugs hit the market.

But this is a very slippery slope.  In fact, I can’t help but wonder if we may be too far down that slope already.  For better or for worse, Steve Stahl’s books have become de facto “standard” psychiatry texts, replacing classics like Kaplan & Sadock, the Oxford Textbook, and the American Psychiatric Press books.  Stahl’s concepts are easy to grasp and provide the paradigm under which most psychiatry is practiced today (despite his own misgivings—see above).  However, his industry ties are vast, and his “education” company, Neuroscience Education Institute (NEI), has close connections with medical communications companies who are basically paid mouthpieces for the pharmaceutical industry.  Case in point: Arbor Scientia, which was hired by Sunovion to organize yesterday’s symposium—and similar ones in other cities—shares its headquarters with NEI in Carlsbad, CA, and Mr Davis sits on NEI’s Board.

We may have already reached a point in psychiatry where the majority of what we consider “education” might better be described as marketing.  But where do we draw the line between the two?  And even after we answer that question, we must ask, (when) is this a bad thing?  Yesterday’s Sunovion symposium may have been an infomercial, but I still felt there was a much greater emphasis on the “info-” part than the “-mercial.”  (And it’s unfortunate that I’d be reported as a recipient of pharmaceutical money if I had attended the conference after January 1, 2012, but that’s for another blog post.)  The question is, who’s out there to make sure it stays that way?

I’ve written before that I don’t know whom to trust anymore in this field.  Seemingly “objective” sources—like lectures from my teachers in med school and residency—can be heavily biased, while “advertising” (like yesterday’s symposium) can, at times, be fair and informative.  The end result is a very awkward situation in modern psychiatry that is easy to overlook, difficult to resolve, and, unfortunately, still ripe for abuse.

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Is Weiner Really Such A Bad Guy?

June 25, 2011

I don’t use this blog as a platform for political opinions or broad social commentary, but the Anthony Weiner “sexting” fiasco has raised some issues in my mind.  And I guess, in a roundabout way, it actually does pertain to psychiatry and medicine, so I figured I’d share these thoughts.

Unless you’ve been exiled to the Gulag for the last month, you probably know that Weiner, a Democratic New York congressman, was forced to resign from his post after the outcry over lewd photographs he sent to women from his Twitter account.  He left his office in disgrace and is apparently entering rehab.  (Maybe I’ll write about the wisdom of that move in a different post.)

The thing is, Weiner was a generally well-liked Congressman and was reportedly a leading candidate to run for mayor of New York in 2013.    He had many supporters and, until the “Weinergate” scandal broke, was seen as a very capable politican.  One might argue, in fact, that his sexual exploits had no effect on his ability to legislate, despite the vociferous (and at times rabid) barbs levied upon him by pundits and critics after the scandal became public.

Now, don’t get me wrong.  I am not condoning his behavior.  I am not saying that we should ignore it because “he’s otherwise a good guy.”  In no way should we turn a blind eye to something that shows such poor taste, a profound lack of judgment, and a disregard for his relationship with his wife.

But does it require the sudden unraveling of an entire political career?  Weiner has done some bad things.  But do they make him a bad congressman?

Some of the same questions arose during the recent flurry of stories about doctors who speak for drug companies.  As ProPublica has written in its “Dollars for Docs” series, some doctors have earned tens of thousands of dollars speaking on behalf of companies when they are also expected to be fair and unbiased in their assessment of patients, or in their analysis and presentation of data from clinical trials.

This is, in my opinion, a clear conflict of interest.  However, some of the articles went one step further and pointed out that many of those doctors have been disciplined by their respective Medical Boards, or have had other blemishes on their record.  Are these conflicts of interest?  No.  To me, it seems more like muckraking.  It’s further ammunition with which critics can attack Big Pharma and the “bad” doctors who carry out its dirty work.

Now I don’t mean to say that every sin or transgression should be ignored.  If one of those doctors had been disciplined for excessive or inappropriate prescribing, or for prescription fraud, or for questionable business practices, then I can see why it might be an issue worthy of concern.  But to paint all these doctors with a broad stroke and malign them even further because of past disciplinary action (and not simply on the basis of the rather obvious financial conflicts of interest), seems unfair.

The bottom line is, sometimes good people do bad things.  And unfortunately, even when those “bad things” are unrelated to the business at hand, we sometimes ruin lives and careers in our attempts to exact justice.  Whatever happened to rehabilitation and recovery?  A second chance?  Can we evaluate doctors (and politicians) by the quality of their work and their potential current conflicts, rather than something they did ten or twenty years ago?

(By the way, there are some bad—i.e., uninformed, irresponsible—doctors out there who have no disciplinary actions and no relationships with pharmaceutical companies.  Where are the journalists and patient-advocacy groups looking into their malfeasance?)

In our society, we are quick to judge—particularly those in positions of great power and responsibility.  And those judgments stick.  They become a lens through which we see a person, and those lenses rarely come off, regardless of how hard that person has worked to overcome those characterizations.  Ask any recovered alcoholic or drug addict.  Ask any ex-felon who has cleaned up his act.  Ask any “impaired professional.”  (In the interest of full disclosure, I am one of those professionals, whose “impairments” stemmed from a longstanding mental illness [now in remission] and affected none of my patients or colleagues, but which have introduced significant obstacles to my employability for the last five years.)  And ask any politician who has had to surrender an office due to a personal failing like Weiner’s.

Come to think of it, ask any patient who has been given a psychiatric diagnosis and whose words and actions will be interpreted by her friends, family,  doctors, or boss as part of her “borderline personality” or “bipolar” or “psychosis.”  It’s hard to live that down.

When evaluations matter, we should strive to judge people by the criteria that count, instead of the criteria that strengthen our biases, confirm our misconceptions, and polarize us further.  If we are able to do so, we may make it easier for people to recover and emerge even stronger after making mistakes or missteps in their lives.  We also might get along with each other just a little better.


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