The going rate on shrinks:
Big Pharma and the buying of psychiatry

by E. Fuller Torrey, MD
The American Prospect

July 15, 2002

Reprinted with permission from the author. All rights reserved. Visit the American Prospect online.

It was last summer in Berlin when I first encountered pharmaceutical funhouses. I was one of 4,000 attendees at the 7th World Congress of Biological Psychiatry. Until about a decade ago, pharmaceutical companies passed out pens or notepads with their companies’ logos at such events, and most speakers presented data and opinions based upon their true scientific beliefs.

That all changed when Big Pharma took over. At thecongress, I counted 15 major displays on the way to the lunch area, including anartificial garden (Janssen-Cilag), a brook running over stones (Lundbeck), and a 40-footrotating tower (Novartis). Almost all offered free food and drink, T-shirts, or otherinducements designed to get psychiatrists to pause so that an army of smiling salesrepresentatives could give their sales pitch.

Eli Lilly’s display included two large, walk-throughtunnels set up like funhouses. One tunnel, labeled “Zyprexa,” included amirrored room with dozens of telephones dangling from the ceiling. Was Lilly trying toconvince me that God was calling, telling me to prescribe Zyprexa? The salesrepresentative said no, the phones were meant to illustrate the communication problemscommon in schizophrenia, which Lilly claims Zyprexa improves. The other funhouse, labeled”Prozac,” featured a 10-foot mouselike creature sitting in front of a blanktelevision screen. I asked whether Lilly was recommending Prozac for mice. Therepresentatives said no, the creature was really a depressed man who needed Prozac.

My favorite display, by the Dutch firm Organon, advertisedRemeron, an antidepressant. It featured a small, multihued tent with purple doors and thepainted head of a genie. Inside, a red-robed young woman with sprinkles in her hair wastaking Polaroid pictures, one by one, of psychiatrists who had waited patiently in linefor 20 minutes or more. This was no ordinary picture but rather a snapshot of one’s aura,taken, as the Organon brochure noted, “with advanced biofeedback equipment.” Theequipment consisted of two small machines, on which I placed my hands. The result was apicture of my head peering out of a red, orange, and yellow cloud.

According to the brochure, “the aura colors give youinformation about your appearance, character, talents, and future energy.” Aftertaking my picture, the red-robed young woman escorted me to a yellow-robed young womanwith even more sprinkles in her hair. “Hi! My name is Amber,” she said, andproceeded to interpret the picture of my aura as indicating intelligence and goodjudgment, although with some hints of skepticism.

I privately asked the Organon sales staff if they thoughtit wise to associate their product with auras, magic, New Age thinking, and anti-science.They said the decision had been made at “a higher level” but pointed out thatthe waiting line was an ideal place for engaging psychiatrists in brief, friendly chatsabout the virtues of Remeron.

This is, after all, big business. Antidepressant andantipsychotic drugs are among America’s top-selling pharmaceuticals. Last year Prozac andZyprexa accounted for almost half of Eli Lilly’s total sales. Sales of antipsychoticmedications have quadrupled in the past four years to more than $4billion. These drugs area major reason why the profitability of the 11 pharmaceutical companies in the Fortune 500″was almost four times greater” than the median for all Fortune 500 companiesduring the 1990s, according to a report by the Public Citizen Health Research Group.

Not surprisingly, psychiatrists have become a prime targetof pharmaceutical companies’ marketing, because prescription drugs can’t be sold directlyto consumers. In the United States, pharmaceutical companies spend an estimated $8,000 to$13,000 per physician per year on marketing.

At professional gatherings, of course, one must offer theattending psychiatrist more than an opportunity to view one’s aura. The Berlin Congressoffered 136 symposia plus workshops and lectures. Of these, 23 were clearly labeled asbeing sponsored by pharmaceutical companies; all focused on drugs to treat psychiatricdisorders. Several other industry-sponsored talks had no disclosure of the sponsorship.

Each brought in two to four psychiatric experts, whom thesponsoring pharmaceutical company usually gave business-class air tickets, four-star hotelaccommodations, and an honorarium, typically $2,000 to $3,000. If the expert organized thesymposium, the payments went as high as $5,000, and higher still if the expert presenteddata very favorable to that company’s drug (or at least presented unfavorable data in avery favorable light). One American expert was paid $10,000 last year to fly to Europe togive a single lecture.

Symposia and workshops on subjects not directly concernedwith drug prescriptions had little, if any, industry support. The speaker at one suchsymposium, which was lightly attended, said he “felt like the legitimate act at aburlesque show, included only to keep the cops out.”

Honoraria and future invitations are directly dependent onhow experts present their data. Emphasizing adverse effects of a drug, for example, maywell cost the expert a trip to future congresses. Some of the psychiatric expertssponsored by a pharmaceutical company are also on the company’s speakers bureau; many ownstock and thus have a direct financial interest in the success of the company’s products.

The ultimate targets for this pharmaceutical extravaganza,of course, are the practicing psychiatrists who constitute the vast majority of attendees.Although meeting officials won’t provide precise numbers, they acknowledge thatpharmaceutical companies had sponsored more than half of the attendees. Sponsorshipnormally includes coach-class airfare, hotel accommodations, and registration fees as wellas special receptions and parties, some literally with dancing girls.

Pharmaceutical companies in many countries can now usecomputerized pharmacy databases (which delete the names of the patients) to track how manyprescriptions any given physician writes for any given drug. So Eli Lilly could sponsorDr. Smith from Detroit or Manchester, send him to Berlin, and then monitor his prescribingpattern following the congress. If Dr. Smith’s prescriptions for Zyprexa and Prozac do notincrease sufficiently, a company representative can remind him how well he was treated inBerlin. And besides, isn’t he interested in going to Copenhagen next summer?

There is clear evidence that attending conferences such asthe Berlin meeting does affect the prescribing practices of physicians. In one U.S. study,10 physicians were invited by a pharmaceutical company to attend “all-expensespaid” symposia at “popular Sunbelt vacation sites.” The company tracked thephysicians’ prescribing patterns for two drugs, for 22 months before and 17 months afterthe symposia. Though the physicians had predicted that their attendance would not affecttheir prescribing practices, their prescriptions for one drug increased 87 percent and forthe other, 272 percent. Other studies have shown that attending drug-sponsored educationcourses affects drug-prescribing practices, even though the physicians deny it. Indeed, ifit were otherwise, why would pharmaceutical companies sponsor such activities?

Does any of this really matter? It does, for two reasons.First, patient care suffers when physicians are misled. Psychiatrists trying to evaluateschizophrenia drugs are not told that the expert who minimizes the side effects of Zyprexareceives a $10,000 retainer from Eli Lilly and also owns substantial company stock. Orthat the psychiatric expert claiming that Remeron reverses depression more rapidly insuicidal patients receives $75,000 per year from Organon to support his laboratory.

Second, the hoopla adds to the cost of drugs. Payments toaura interpreters and dancing girls are simply passed on to patients. The pharmaceuticalcompany costs for the Berlin congress were at least $10 million. According to a recentreport, in 2000 the 11 pharmaceutical firms in the Fortune 500 “devoted nearly threetimes as much of their revenue to marketing and administrative costs (30 percent ofrevenue) as to research and development (12 percent of revenue).”

Plainly some changes are in order. Reform should start withmedical students. As one observer summarized it in The New England Journal of Medicine:”Medical training should not include acquiring a sense of entitlement to the largesseof drug companies.” Pharmaceutical companies should be banned from giving gifts tomedical students and residents; the free pizza from the drug representative may seemtrivial, but it sets a pattern that rationalizes accepting a free trip to Berlin later on.Practicing psychiatrists should get their continuing education from objective sources, notfrom drug “detail” (marketing) persons and industry-sponsored talks. Vermont hasjust made a modest beginning with a law requiring disclosure of all drug-company gifts todoctors valued at more than $25. The profession’s ethical standards should prohibitexperts who are involved in drug trials or giving talks at symposia from owning stock inpharmaceutical companies. Unfortunately, most of the profession’s organizations, such asthe American Psychiatric Association, are themselves so indebted to drug companies thatthey are unlikely to lead reform.

For speakers at symposia such as the Berlin meeting, thesolution is simple. Prominently displayed next to the speaker’s lectern should be a signreading: “For this talk, Dr. Smith is being paid $3,500, business-class airfare, andfour-star hotel accommodations by Eli Lilly and Company.”

Copyright © 2002 by The American Prospect, Inc.Preferred Citation: E. Fuller Torrey, “The Going Rate on Shrinks,” The AmericanProspect vol. 13 no. 13, July 15, 2002 . This article may not be resold, reprinted, orredistributed for compensation of any kind without prior written permission from theauthor. Direct questions about permissions to