The report by the New York Times today that a 1999 medical text authored by Dr. Charles Nemeroff and by Dr. Alan Schatzberg was ghostwritten and financed by a pharmaceutical firm seems—at first glance—to tell of a new level of corruption within American medicine. “To ghostwrite an entire textbook is a new level of chutzpah,” former FDA commissioner David Kessler told the New York Times. “I’ve never heard of that before.”
But, in fact, this ghostwriting revelation simply hints at a much larger, very pervasive problem, which is that financial lbias profoundly affects the authorship of psychiatric textbooks at every turn. And it is quite easy to document that this is so.
In its article, the New York Times reported that SmithKline Beecham (now part of GlaxoSmithKline) had provided Nemeroff, who today is chairman of psychiatry at the University of Miami medical school, and Schatzberg, who was chairman of psychiatry at Stanford University from 1991 to 2009, with an “unrestricted educational grant” to author “Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care.” But SmithKline Beecham also paid a writing company, Scientific Therapeutics Information, to develop an outline for the book and—apparently—to actually write the text. Once the ghostwritten book was published, SmithKline Beecham purchased 10,000 copies for distribution to American family physicians.
This is indeed egregious. But the larger problem is this: Commercial interests influence the writing of most psychiatric texts.
First, psychiatric textbooks are regularly authored by leading psychiatrists at academic medical centers, many of whom are paid by pharmaceutical companies for their work as “advisors, consultants, and speakers.” Thus, while writing a particular textbook they may not be receiving any money from a pharmaceutical company, they still have an ongoing financial relationship with the makers of psychiatric medications. As such, they have a financial reason for writing about psychiatric medications in a way that promotes their use.
Second, psychiatry as a field naturally has reason to promote the safety and efficacy of psychiatric medications. After all, this is the field’s main product today. Psychiatrists have turned into psychopharmacologists, and you can’t expect the leaders in the field to author texts that might question the fundamental merits of that product.
In my book Anatomy of an Epidemic, I investigated this storytelling process. In the first sections of the book, I reported on a number of studies funded by the National Institute of Mental Health, the World Health Organization, and other governmental agencies that told of unmedicated psychiatric patients doing better over the long-term than those who stayed on the drugs. In the latter part of the book, I investigated whether these studies were ever written about in psychiatric texts. Here’s what I found: None of the studies was discussed at any length, and in the few instances when one of the studies was mentioned in a textbook, the authors spun the results to protect the image of the drugs.
For instance, Martin Harrow, a researcher from the University of Illinois College of Medicine, reported in 2007 on the 15-year outcomes of a group of schizophrenia patients he had been following since the early 1980s. Forty percent of the patients off antipsychotic medications were in recovery at the end of 15 years, versus five percent of those on medication. He also reported on the 15-year outcomes of patients with milder psychotic disorders, and once again it was those off antipsychotics that were doing much better.
Now, this is the best longitudinal study of modern schizophrenia outcomes that we have today. This was an important NIMH-funded study. So how did the authors of the 2009 edition of the American Psychiatric Association’s Textbook of Psychiatry deal with it? They mentioned the study in passing, but they didn’t detail the actual results. They didn’t report that the recovery rate for unmedicated patients was eight times higher than for the medicated patients; instead the authors simply wrote that Harrow’s study reveals that there are some schizophrenia patients who are “able to function without the benefit of continuous antipsychotic treatment.”
This was spinning at its best. The authors came up with a sentence that told of the “benefit of continuous antipsychotic treatment.”
Now, let’s put this larger storytelling process together. As is well known now, the published scientific literature on the clinical testing of psychiatric medications during the past 20 years does not accurately portray the efficacy and safety of those drugs. Trials were biased by design, results were spun, articles were ghostwritten, and negative results went unpublished. As such, the source literature is corrupted, and that tainted literature then serves as the source material for authors who write psychiatric texts. Then those authors—when confronted with an upsetting study like Harrow’s—add their own layer of spin.
The New York Times article tells of a ghostwritten book, and observers—like former FDA commissioner David Kessler—express their shock. But it’s really not so out-of-step with larger storytelling forces that have been at work in psychiatry for some time.
Tuesday, November 30, 2010