Anatomy of an Epidemic (48 page)

Naturally, this flourishing business enterprise generates great personal wealth for executives at pharmaceutical companies, and money also flows in fairly copious amounts to the academic psychiatrists who tout their drugs. Indeed, the profits from this enterprise trickle down to nearly all of those who tell the “psychiatric drugs are good” story to our society. To get a sense of the amounts involved, we can look at the money that the different players in this enterprise receive.

We can start with Eli Lilly, as it serves as a good example of the profits that go to a drug company’s shareholders and its executives.

In 1987, Eli Lilly’s pharmaceutical division generated $2.3 billion in revenues. The company did not have a central nervous system drug of any importance, as its three bestselling drugs were an oral antibiotic, a cardiovascular drug, and an insulin product. Eli Lilly began selling Prozac in 1988, and four years later it became the company’s first billion-dollar drug. In 1996, Eli Lilly brought Zyprexa to market, and it became a billion-dollar drug in 1998. By 2000, these two drugs accounted for nearly half of the company’s revenues of $10.8 billion.

Prozac soon after lost its patent protection, and thus the wealth-generating effects of the two drugs can best be assessed across a thirteen-year period, from 1987 to 2000. During this time, Eli Lilly’s value on Wall Street rose from $10 billion to $90 billion. An investor who bought $10,000 of Eli Lilly stock in 1987 would have seen that investment grow to $96,850 in 2000, and along the way the investor would have received an additional $9,720 in dividends. At the same time, Eli Lilly’s executives and employees, in addition
to their salaries and bonuses, netted around
$3.1 billion
from the stock options they exercised.
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The pharmaceutical companies would not have been able to build a $40 billion market for psychiatric drugs without the help of psychiatrists at academic medical centers. The public looks to doctors for information about illnesses and how best to treat them, and so it was the academic psychiatrists—paid by drug companies to serve as consultants, on advisory boards, and as speakers—who in essence acted as the salesmen for this enterprise. The pharmaceutical companies, in their internal memos, accurately call these psychiatrists “key opinion leaders,” or KOLs for short.

Thanks to a 2008 investigation by Iowa senator Charles Grassley, the public got a glimpse of the amount of money that the pharmaceutical companies pay their KOLs. The academic psychiatrists regularly receive federal NIH grants, and as such, they are required to inform their institutions how much they receive from pharmaceutical companies, with the medical schools expected to manage the “conflict of interest” whenever this amount exceeds $10,000 annually. Grassley investigated the records of twenty or so academic psychiatrists, and he found that not only were many making much more than $10,000 a year, they were also hiding this fact from their schools.

Here are a few examples of the money paid to KOLs in psychiatry.

• From 2000 to 2007, Charles Nemeroff, chair of the psychiatry department at Emory Medical School, earned at least $2.8 million as a speaker and consultant for drug firms, with GlaxoSmithKline alone paying him $960,000 to promote Paxil and Wellbutrin. He is a coauthor of the APA’s
  Textbook of Psychopharmacology
  , which is the bestselling textbook in the field. He also wrote a trade book about psychiatric medications,
  The Peace of Mind Prescription
  , for the general public. He has served on the editorial boards of more than sixty medical journals and for a time was editor in chief of
  

• Neuropsychopharmacology
  . In December of 2008, he resigned as chair of Emory’s psychiatry department, as he had failed to inform Emory of his drug-company paychecks.
  ¹⁵
  

• Zachary Stowe, also a professor of psychiatry at Emory, received $250,000 from GlaxoSmithKline in 2007 and 2008, partly to promote the use of Paxil by breast-feeding women. Emory “reprimanded” him for failing to properly disclose these payments to the school.
  ¹⁶
  

• Another member of GlaxoSmithKline’s speaker bureau was Frederick Goodwin, a former director of the NIMH. The company paid him $1.2 million from 2000 to 2008, mostly to promote the use of mood stabilizers for bipolar illness (GlaxoSmithKline sells Lamictal, which is a mood stabilizer). Goodwin is the coauthor of
  Manic-Depressive Illness
  , the authoritative textbook on this disorder, and he also was the longtime host of a popular radio show,
  The Infinite Mind
  , which was carried on NPR stations nationwide. His show regularly featured discussions of psychiatric medications, with Goodwin, in a program broadcast on September 20, 2005, warning that if children with bipolar disorder were not treated, they could suffer brain damage. Goodwin has been a speaker or consultant for a number of other pharmaceutical companies; the $1.2 million was what he received from GlaxoSmithKline alone. In an interview with the
  New York Times
  , Goodwin explained that he was only “doing what every other expert in the field does.”
  ¹⁷
  

• From 2000 to 2005, Karen Wagner, director of child and adolescent psychiatry at the University of Texas, collected more than $160,000 from GlaxoSmithKline. She promoted the use of Paxil in children, and did so in part by coauthoring an article that falsely reported the results of a pediatric trial of the drug.
  

  In a confidential document written in October 1998, GlaxoSmithKline concluded that in the study, Paxil “failed to demonstrate a statistically significant difference from placebo on the primary efficacy measures.”
  ¹⁸
  In addition, five of the ninety-three adolescents treated with Paxil in the study
  suffered “extreme lability,” versus one in the placebo group, which meant that the drug markedly elevated the suicide risk. The study had shown Paxil to be neither safe nor effective in adolescents. However, in a 2001 article published in the
  Journal of the American Academy of Child & Adolescent Psychiatry
  , Wagner and twenty-one other leading child psychiatrists stated that the study proved that Paxil is “generally well tolerated and effective for major depression in adolescents.”
  ¹⁹
  They did not discuss the sharply elevated suicide risk, writing instead that only one child treated with Paxil had suffered a serious adverse event, with that child developing a “headache.” New York State attorney general Eliot Spitzer sued GlaxoSmithKline for fraudulently marketing Paxil to adolescents, a case which was settled out of court.
  

  All told, Wagner has been a consultant or advisor to at least seventeen pharmaceutical companies. The $160,000 was the amount she received from GlaxoSmithKline alone; she told her school that she had received $600.
  ²⁰
  

• From 1999 to 2006, Jeffrey Bostic, a psychiatrist at Massachusetts General Hospital in Boston, collected more than $750,000 from Forest Laboratories to promote the prescribing of Celexa and Lexapro to children and adolescents. He gave more than 350 talks in twenty-eight states during this period, leading one Forest sales rep to boast: “Dr. Bostic is the man when it comes to child psych!”
  ²¹
  In March of 2009, the federal government charged Forest with illegally marketing these drugs to this patient population, alleging that it had paid “kickbacks, including lavish meals and cash payments disguised as grants and consulting fees, to induce doctors to prescribe the drugs.” Dr. Bostic, the federal government said, served as the company’s “star spokesman” in this scheme. The federal government noted that the company had also failed to disclose the results of a study of these drugs in children that had produced “negative” results.
  

• From 2003 to 2007, Melissa DelBello, an associate professor of psychiatry at the University of Cincinnati, received at least $418,000 from AstraZeneca. She promoted the prescribing
  of atypical antipsychotics, including AstraZeneca’s Seroquel, to juvenile bipolar patients. DelBello worked for at least seven other pharmaceutical companies. “Trust me, I don’t take much” from drug firms, she told the
  New York Times
  prior to Grassley’s report.
  ²²
  

• Joseph Biederman may have been the KOL who did the most to help the pharmaceutical industry build a market for its products. To a large extent, juvenile bipolar illness was his creation, and children and adolescents so diagnosed are often treated with drug cocktails. Pharmaceutical companies paid him $1.6 million for his various services from 2000 to 2007, with much of this money coming from Janssen, the division of Johnson & Johnson that sells Risperdal.
  ²³
  

  Biederman also got the company to pay $2 million from 2002 to 2005 to create the Johnson & Johnson Center for Pediatric Psychopathology at Massachusetts General Hospital.
  ²⁴
  In a 2002 report on the center, he candidly set forth its aims. The center, he explained, was a “strategic collaboration” that would “move forward the commercial goals of J&J.” He and his colleagues would develop screening tests for juvenile bipolar illness, and then teach CME (continuing medical education) courses to train pediatricians and psychiatrists to use them. Their research, Biederman wrote, would “alert physicians to the existence of a large group of children who might benefit from treatment with Risperdal.” In addition, the center would promote the understanding that “pediatric mania evolves into what some have called mixed or atypical mania in adulthood, [which] will provide further support for the chronic use of Risperdal from childhood through adulthood.”
  ^*
  In the past, Biederman noted, he had successfully led the medical profession to conceive of ADHD as a “chronic” illness, and now he would do the same for bipolar disorder.
  ²⁵
  

  Biederman has been the Pied Piper of pediatric bipolar illness in our society, and in this document we can see the future that he was laying out for the children given this diagnosis. They were being groomed to be lifelong consumers of psychiatric medications. The child diagnosed with bipolar disorder would be put on an antipsychotic, and that child could then be expected to become chronically ill, and that would require a lifetime of “aggressive treatments such as Risperdal.” Perhaps there is a file tucked away in a drug company cabinet that estimates the expected lifetime consumption of psychiatric medications by a child diagnosed with bipolar illness; all we can say, in this book, is that every child so diagnosed is, from a business standpoint, a new Jenna.
  

The KOLs are the “stars” of the field, as they are the ones who “influence” their peers at a national and international level, but the pharmaceutical companies also pay physicians to promote their drugs on a more local basis, with these speakers giving talks at dinners or to other physicians in their offices. Pay typically starts at $750 per event and rises from there. Two states, Minnesota and Vermont, have passed “sunshine” laws that disclose these payments, and their reports provide insight into the flow of money to these doctors.

In 2006, pharmaceutical firms gave $2.1 million to Minnesota psychiatrists, up from $1.4 million in 2005. From 2002 to 2006, the recipients of drug-company money included seven past presidents of the Minnesota Psychiatric Society and seventeen faculty psychiatrists at the University of Minnesota. John Simon, who was a member of the state’s Medicaid formulary committee, which guides the state’s spending on drugs, was the top-paid psychiatrist, earning $570,000 for his services to drug companies. All told, 187 of 571 psychiatrists in Minnesota received pharmaceutical money for some reason or other during this period, a percentage that was “much
higher” than for any other specialty. Their collective take was $7.4 million.
²⁶

Vermont’s reports tell much the same story. Of all the medical specialties, psychiatry received the most money from the drug companies.

The pharmaceutical companies also provide freebies to community psychiatrists. They invite them to free dinners where the KOLs and the local experts give their talks, and their sales representatives regularly come to their offices bearing small gifts. “Gave Dr. Child a cupcake sized peanut butter cup,” wrote an Eli Lilly sales representative, in a 2002 report to her boss. “He was kind of tickled.” Or as she said after another sales call: “Doc and staff loved the goodie box I brought in, filled with useful items for their new clinic.”
²⁷
These are very small bribes, but even a small gift helps build a social bond. A California group surveyed the drug firms and found that they do set a limit on the freebies that are offered to a psychiatrist each year; GlaxoSmithKline’s was $2,500 per physician, while Eli Lilly’s was $3,000. There are many companies that sell psychiatric drugs, and thus any psychiatrist who welcomes sales reps can enjoy a regular supply of goodies.

Eli Lilly now posts on the Web a list of the “educational” and “philanthropy” grants it makes, and this provides a peek at the money going to patient advocacy groups and various educational organizations. In the first quarter of 2009 alone, Eli Lilly gave $551,000 to NAMI and its local chapters, $465,000 to the National Mental Health Association, $130,000 to CHADD (an ADHD patient-advocacy group), and $69,250 to the American Foundation for Suicide Prevention. The company gave more than $1 million to various educational organizations, including $279,533 to the Antidote Education Company, which runs a “continuing medical education” course. Those are the amounts from one pharmaceutical company
for three months; any full accounting of the flow of money to patient advocacy groups and educational organizations would require adding up the grants from all of the makers of psychiatric drugs.
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