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.
I may be wrong but I bet the Sunovian Marketing Department folks are giving themselves “high fives” after reading your post! Access to Stahl with a minor mea culpa offered by His Highness and some computer games and a lunch and lo and behold Thought Broadcast reads, subliminally, like a commercial for Latuda! Made me feel warm and fuzzy!
If they’re giving themselves high-fives, they first should realize that they’ve invested a large sum of money in obtaining a very small number of new prescriptions (like, um, zero) from me.
I didn’t mean for this to be a commercial for Latuda, but rather an endorsement of the educational—dare I say “pedagogic”— approach taken by Sunovion. Where can a doctor learn about Fanapt, Saphris, Viibryd, Nuedexta, Abilify, etc., etc., in the same way? Glossy ads? Drug reps? TV? No, no, and no.
Sunovion clearly paid a lot for this weekend’s event. Most of this went to Steve Stahl’s company (and probably into Dr Stahl’s pockets), but it also helped to educate attendees in ways that “conventional” approaches do not: textbook chapters on Latuda won’t appear for several years; journal articles are inaccessible to non-academic psychiatrists; and TV and journal ads are heavily biased and short on detail.
I still don’t know whether Latuda is a better drug than anything else on the market, but after yesterday’s event I know more about it. That’s a plus. The question is: is this the way we should be educating prescribers?
If this wasn’t an infomercial for Latuda, then shame on Sunovion for failing to do its job.
But I rather think the symposium achieved the desired effect: it left you feeling favorably disposed towards the company. That, I would suggest, was the job Sunovion set out to accomplish, rather than getting you to move this particular product. You’re a fan now. That’s Candyland for a Pharmceutical house.
At least Rob sees it my way.
Actually, this is interesting. Trust me, I’m no apologist for the drug industry (and, BTW, I have no relationship with Sunovion), but I was prepared for a flashy Latuda extravaganza. Instead, I walked away with a greater understanding of this drug– the good and the bad. And Rob, I’m still not a “fan” of Latuda (I just don’t see how it fits into my practice, even after Saturday), but I did appreciate how Sunovion made it easy for me & others to learn about it.
I wrote this post because it’s all too easy to demonize doctors (for “taking money” from pharma) and drug companies (for buying our influence), when in fact there are shades of gray on both sides. I’m sure I’d be shocked to hear how much money was spent by Sunovion on Saturday’s symposium (which is itself a topic worthy of another discussion), but in my opinion, most of it went to educating us about clinical trial data rather than extolling Latuda’s virtues relative to Seroquel, Abilify, and its competitors.
When you buy a car, you probably go online and download specs from the automaker’s website, rather than drive from dealership to dealership and speak to salespeople, right? To me, this symposium was the equivalent of the corporate homepage, whereas the semi-weekly visits by reps (and their glossy handouts & Panera sandwiches) are the showroom sales pitches. Yes, there is a difference.
Regarding car buying, the real learning about what I wanted to purchase took place when I rented a car during the time I specifically needed one. Being able to drive the car under realistic conditions without the influence of a salesmen led me to finally make my decision as to what to buy.
It sounds like your best learning about Latuda already took place before you even went to the presentation by Sunovian. You learned in our own practice that so far, it seems to be a mediocre drug although of course, 3 patients does not make for a sample size.
I didn’t try too many cars either but both of us I think learned best what we wanted to know under conditions without any influence.
I think what Rob’s worried about is that you’ve come away feeling positive (even if only slightly) about Latuda (or the parent company – but feelings inevitably rub off onto related things) on the basis of a Latuda marketing event.
Granted the reason you feel positive is that the event seemed to be fair and balanced.
But that’s still feeling positive and it’s still a marketing event, at the end of the day.
“In all honesty, I’m no more likely to prescribe Latuda today than I was last week.”
I’m sure that’s your honest feeling, but I believe you’re mistaken. Empirical studies have shown that prescription rates rise after exposure to such infomercial presentations. And really, it only makes sense: You’re now thinking about Latuda, blogging about it, it’s more cognitively salient to you than before. It’s like telling yourself, “Don’t think of elephants!” After repeating that a few times, damn near everything sort of looks like an elephant.
“(when) is this a bad thing?”
That has a complex answer, but for starters: When it leads MDs to prescribe brand-name products — the only ones promoted — versus generic alternatives we’d otherwise prescribe. When non-prescription alternatives such as psychotherapy, dietary changes, etc are overlooked because they’re not promoted (this pertains more to antidepressants than atypicals, but consider how much the latter are now used for *insomnia*). When it further blurs what marketing is, such that product placement in movies, selling ad space on the side of your car, and brand-name sports arenas becomes the norm. Several authors have written whole books on these and other reasons to be concerned.
“it’s unfortunate that I’d be reported as a recipient of pharmaceutical money if I had attended the conference after January 1, 2012”
Not at all. Because you did. As I commented on your last post, maybe small amounts should fall beneath a reporting threshold. But conceptually it’s just a matter of degree. Sunovion spent good money to get you thinking fun, happy thoughts about their product. Obviously they did it so you’d prescribe Latuda. Your goals may have been different, but that’s not what such reporting is about.
If I have any “fun, happy thoughts,” they’re not about Latuda; they’re about the manner in which I was educated about Latuda last weekend.
Latuda is more “cognitively salient” to me because someone took the time– and the expense– to teach me about it. Unfortunately (for Sunovion), I didn’t learn anything that sets it apart from other agents with which I’m more familiar. But I did learn something. Many Pharma naysayers (of which I can certainly be one) don’t recognize that “drug money” sometimes helps to educate doctors, and that’s not always a bad thing, especially when you consider the alternatives (journal ads, poorly informed drug reps, fancy websites, etc).
Anyway, I agree with you that “prescription rates rise after exposure to such infomercial presentations.” But whose “fault” is this? The drug companies’? Not necessarily: last weekend’s Latuda presentation did not convert me into a Latuda prescriber. On the other hand, I’m sure there were some in the room who have been prescribing Latuda all week when Risperdal (or Haldol) would have worked just fine. For this, how much blame goes to Sunovion, and how much to the doctors for blindly following Dr Stahl and his pronouncements from on high?
I apologize if my line about “fun, happy thoughts” came across as flippant. Nonetheless, I was trying to make a serious point. Advertising “sells the sizzle, not the steak.” Products are not marketed to your cerebral cortex by offering lists of features and benefits, but to your limbic system by associating the product with a favorable mood or image. Thus, meals and entertainment are business deductions, and deals are sometimes struck on the golf course.
Pharmaceutical companies follow this tradition by associating their products and marketing messages with good food and fun. You needn’t feel fondly toward Latuda itself, just the nice folks who make or talk about it — a “halo effect”. Moreover, none of this is incompatible with learning useful facts. A very compelling and evocative car commercial can tug at your heartstrings, but in the end it’s a SUV when you really wanted a convertible. “Limbic marketing” doesn’t make us mindless zombies, but it does have a profound influence, one that doctors seem especially resistant to acknowledge.
Does “drug money” sometimes educate doctors? Of course. The question is, at what price? Sunovion does what all companies do: tries to move product. Doctors try to stay thoughtful and objective. It isn’t a question of fault, but of honoring our professional goals and values — taking into account that even a superior cerebral cortex comes attached to an all too human limbic system.
I don’t agree that any of Stahl’s “texts” have replaced our classics anymore than hip hop has replaced Beethoven. And the fact that he admitted to you that he doesn’t even believe all of his fancy schmancy pharmacodynamic dogma only adds to his “hired gun” charlotan status.
Dr. Steve, that Sunovion got you to *consider* Latuda, even momentarily, counts as a successful marketing outing.
To use the current nonsensical psychiatric explanation, you think you admire Sunovion’s design of the experience. but it established neurological circuits in your brain giving you an inclination towards Latuda.
Just for laughs, how well did they cover the adverse effects?
I find it quite interesting that this post has been interpreted as an endorsement of Latuda. If anything, it was my endorsement of the pedagogical methods Sunovion used, and not of the drug itself. Maybe I hold myself to higher standards than most other physicians, but I like to think that I can separate marketing hype from the presentation of data (including adverse effects) about a new drug. (A basic science background and a masters in molecular neuroscience helps, BTW.) In this case– and the main reason I wrote the post– the data were presented in an interactive format that (unfortunately) only a major pharmaceutical company has the money to pull off.
Does that mean it’s a good drug, or that I’ll prescribe it? Entirely different story.
For me, anyway.
No, I interpreted your post as admiring of Sunovion’s pedagogical methods — the design of the experience. A good customer experience lends a certain glamour to the product itself.
Everyone thinks he or she is immune to marketing. I pride myself on this myself. Despite that, once I became fascinated by an infomercial and was even considering buying the product — although I already owned it. (The Braun hand blender, highly recommended.)
And, like everyone else, my Apple products activate those dopamine circuits (joke!) and make me want to buy more Apple stuff.
Yeah, I love my iPhone, too. Neuroimaging told me so.
“Maybe I hold myself to higher standards than most other physicians, but I like to think that I can separate marketing hype from the presentation of data…”
Almost all physicians like to think that. After all, we have superior intellect, razor sharp analytical abilities, and can spot a sales pitch a mile away. Countless times I’ve heard, “I just eat the free lunch, I don’t pay attention to the product.”
While the sentiment is sincere and heartfelt, unfortunately it is simple hubris — the same exceptionalism that led generations of MDs to claim that somehow we could magically work with full precision and alertness around the clock when normal mortals can’t. In this case, it’s the claim that our intellect trumps the emotional lures of marketing, when it’s well-established that intellect has little or nothing to do with it. Indeed, Pharma uses our hubris as a backhanded way to gain access: “Doctor, surely you can weigh the evidence yourself after enjoying our dinner presentation.” As if product promotion were a matter of weighing evidence, or anything so rational.
Of all the medical specialties, psychiatry should be the most sensitive to non-rational influence and emotional persuasion. Paradoxically, our hubris — that we believe we already see through everything and everybody — makes us the most susceptible of all.
While I agree with everything in your comment, I still cannot help but interpret your words as something along the lines of “Yeah, yeah, doc, but deep down, you’re just like the rest of ’em.”
Forgive me if I’m taking your statement too personally, but I feel quite strongly about this. In fact, I like to think that the sentiments expressed throughout my blog suggest that I’m not like the rest of them. If that’s not sufficient, a look at my prescribing patterns would prove the same.
This type of discussion walks a fine line between making a point and getting personal. You and I have never met (despite working nearby), and I admire your writing enough that I recently added you to my blogroll. I’m not aiming to condescend. But the feeling that one is “above” marketing is so widespread in medicine — and demonstrably false — that I feel compelled to say something. Even if you really ARE a statistically improbable outlier, I assure you that most everyone else isn’t.
Dr. R has it right — we’re all susceptible to marketing. Marketers study their target populations and craft approaches that work. They’re the ones who really know how the brain works. They’ve really got evidenced-based activity down.
I have no doubt they factor in an appeal to the doctor egos to make the message go down smoothly. They know who they’re talking to. Wasn’t it flattering to have Dr. Stahl there?
Pharma would not be spending more on marketing than research if it wasn’t more profitable.
There’s a very fine line between pedagogy and propaganda. The proof is in the content — so, Dr. Steve, how did they deal with adverse effects? Were they fully communicated in as convincing a way as the rest of the presentation? Did they have any post-market data?
“Wasn’t it flattering to have Dr. Stahl there?”
Please, Iatrogenia, I hope that was meant as a joke. If not, then frankly it’s an insult to my intelligence.
As for side effects, yes, they were presented in a very clear way (as opposed to in most new drug ads– ie, in small print in the bottom corner– or by most drug reps– ie, not at all), and long-term data included information from 52-week extended-phase trials.
I was teasing, Dr. Steve. I have nothing but respect for your intelligence!
Thanks for this report. Your quote from Dr. Stahl was priceless. I’ve always suspected psychopharmacology was fueled by cynicism, screw the patients.
Recent 1boringoldman on Sunovion and Latuda: http://1boringoldman.com/index.php/2011/12/01/their-choice/
[…]Latuda-Palooza: Marketing or Education? « Thought Broadcast[…]…
IMHO, Arbor Scientia and other companies clearly know where they invest their money for content marketing.
“Seemingly “objective” sources—like lectures from my teachers in med school and residency—can be heavily biased”
I share the same concern in my country (Argentina), in particular about inadvertent bias. Some instructors don’t even question the conflicts of interest behind the sources of information (textbooks, “experts”, throwaway journals).
I wish the international psychiatric community were more open and interested in this type of debates.
Thank you for an excellent post!