EDITORIAL
Many
physicians assume they are immune to the advertising and marketing strategies
of pharmaceutical companies.
Physicians
are confident in their own knowledge and judgment and believe that they will
not be overly influenced by a presentation sponsored by a pharmaceutical
company promoting a specific medication.
Physicians
believe they are resilient enough to see through the ruse of being offered a
reasonably good meal in exchange for sitting through a biased presentation.
These beliefs overlook the more subtle aspects of marketing
tactics.
Marketing
is not primarily about the manipulation
of evidence. Rather Marketing is informed by more basic implicit psychological
processes: leaning theory, cognitive
priming, attachment theory.
Advertising
connects the brand name of a drug with positive
emotional stimuli, pictures of happy patients in pleasing surroundings.
Marketing strategies engage the physician in a
way that promotes positive emotions and memories that are associated with the drug
name. It is done through direct detailing and
the development of positive attachments between the physicians and the drug
reps. It is is done by the provision of gits and financial incentives.
But
there are less obvious and more intricate strategies that large companies and affiliated
physicians may use. For example companies may work to expand the indications
for a particular medication. This can be done in two ways:
i)
claim specific mechanisms of action of a drug that target specific symptoms
thus creating a niche market.
ii)
broaden diagnostic criteria for a
condition by lobbying for changes to DSM.
This
may include the creation of new
diagnostic entities and changing diagnostic thresholds.
This
is made a lot easier when the pharmacological company itself provides
assistance to physicians in making the diagnosis. The company will happily
provide brief diagnostic checklists that
allegedly offer a cut off point that implies the prescription of the new
medication.
The
checklist replaces a comprehensive biopsychosocial assessment.
Some
of these strategies have led to quantum increases in the prescription of antipsychotic
medications across a range of diagnoses. Antipsychotic medications have been
promoted to augment antidepressants in the treatment of depression and anxiety in
the early stages of treatment while the risks of metabolic syndrome and tardive
dyskinesia are downplayed.
There
is even an effort underway to change the name “antipsychotic” to make the use
of these medications in a broad range of conditions more palatable to patients
and physicians (1). This would also make it less apparent that these
medications can cause metabolic syndrome and tardive dyskinesia.
Wakefield
has stated:
“A major pressure unique to psychiatric research today,
and one
that has detrimentally affected the quality of journal
editing, is
the push to publish articles that provide real or
apparent
support for proposed changes in the DSM.
Links between
DSM diagnosis and reimbursement, research funding,
and
approval of pharmacotherapies create non-scientific
motives for
justifying additions to DSM and thus for making
claims that
stretch or go beyond or against the evidence.” (2,3)
And
“Entire
research programmes (e.g. on complicated grief disorder,
or binge
eating disorder) are pursued with the goal in mind of justifying
entry into DSM,
with researchers interpreting their data and reviewers
evaluating
submitted manuscripts through the lens of DSM.
elevated, expansive mood
inflated self-esteem or grandiosity
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
increase in energy or goal-directed activity
increased or excessive involvement in activities that have a high
potential
for painful consequences such as buying sprees, sexual indiscretions
or bad business decisions
decreased need for sleep while still feeling rested.
But these specifiers are core symptoms of
bipolar disorder and that should be the diagnosis! There appears to be no scientific evidence for
or need to invent a new category of mixed depression. This was very puzzling
until I attended a presentation promoting the use of the antipsychotic
medication Lurasidone for “mixed states”.
References
1.
Zohar J, Allgulander C. Antipsychotics in anxiety disorders: An oxymoron or a
reflection of non-adequate nomenclature?
European Neuropsychopharmacology, 21, 6, p.427-428, June 2011.
2.
Wakefield J. The editor’s dilemma: how
DSM politics are
turning psychiatry into a pseudoscience. Acta Psychiatrica Scandinavica 132,
6 p.415 - 502, December 2015.
