The Going Rate on Shrinks
Big Pharma and the buying of psychiatry
By E. Fuller Torrey
Issue Date: 7.15.02
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
That all changed when Big Pharma took over. At the congress, I counted 15 major displays
on the way to the lunch area, including an artificial garden (Janssen-Cilag), a brook
running over stones (Lundbeck), and a 40-foot rotating tower (Novartis). Almost all
offered free food and drink, T-shirts, or other inducements designed to get psychiatrists
to pause so that an army of smiling sales representatives could give their sales pitch.
Eli Lilly's display included two large, walk-through tunnels set up like funhouses. One
tunnel, labeled "Zyprexa," included a mirrored room with dozens of telephones dangling
from the ceiling. Was Lilly trying to convince me that God was calling, telling me to
prescribe Zyprexa? The sales representative said no, the phones were meant to illustrate
the communication problems common in schizophrenia, which Lilly claims Zyprexa improves.
The other funhouse, labeled "Prozac," featured a 10-foot mouselike creature sitting in
front of a blank television screen. I asked whether Lilly was recommending Prozac for
mice. The representatives said no, the creature was really a depressed man who needed
My favorite display, by the Dutch firm Organon, advertised Remeron, an antidepressant. It
featured a small, multihued tent with purple doors and the painted head of a genie.
Inside, a red-robed young woman with sprinkles in her hair was taking Polaroid pictures,
one by one, of psychiatrists who had waited patiently in line for 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." The equipment consisted of two
small machines, on which I placed my hands. The result was a picture of my head peering
out of a red, orange, and yellow cloud.
According to the brochure, "the aura colors give you information about your appearance,
character, talents, and future energy." After taking my picture, the red-robed young woman
escorted me to a yellow-robed young woman with even more sprinkles in her hair. "Hi! My
name is Amber," she said, and proceeded to interpret the picture of my aura as indicating
intelligence and good judgment, although with some hints of skepticism.
I privately asked the Organon sales staff if they thought it 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 that the waiting line was an ideal place for
engaging psychiatrists in brief, friendly chats about the virtues of Remeron.
This is, after all, big business. Antidepressant and antipsychotic drugs are among
America's top-selling pharmaceuticals. Last year Prozac and Zyprexa accounted for almost
half of Eli Lilly's total sales. Sales of antipsychotic medications have quadrupled in the
past four years to more than $4billion. These drugs are a 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 companies during the 1990s, according to a
report by the Public Citizen Health Research Group.
Not surprisingly, psychiatrists have become a prime target of pharmaceutical companies'
marketing, because prescription drugs can't be sold directly to 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 the attending psychiatrist more than
an opportunity to view one's aura. The Berlin Congress offered 136 symposia plus workshops
and lectures. Of these, 23 were clearly labeled as being sponsored by pharmaceutical
companies; all focused on drugs to treat psychiatric disorders. Several other
industry-sponsored talks had no disclosure of the sponsorship.
Each brought in two to four psychiatric experts, whom the sponsoring pharmaceutical
company usually gave business-class air tickets, four-star hotel accommodations, and an
honorarium, typically $2,000 to $3,000. If the expert organized the symposium, the
payments went as high as $5,000, and higher still if the expert presented data very
favorable to that company's drug (or at least presented unfavorable data in a very
favorable light). One American expert was paid $10,000 last year to fly to Europe to give
a single lecture.
Symposia and workshops on subjects not directly concerned with drug prescriptions had
little, if any, industry support. The speaker at one such symposium, which was lightly
attended, said he "felt like the legitimate act at a burlesque show, included only to keep
the cops out."
Honoraria and future invitations are directly dependent on how experts present their data.
Emphasizing adverse effects of a drug, for example, may well cost the expert a trip to
future congresses. Some of the psychiatric experts sponsored by a pharmaceutical company
are also on the company's speakers bureau; many own stock 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 that pharmaceutical companies had
sponsored more than half of the attendees. Sponsorship normally includes coach-class
airfare, hotel accommodations, and registration fees as well as special receptions and
parties, some literally with dancing girls.
Pharmaceutical companies in many countries can now use computerized pharmacy databases
(which delete the names of the patients) to track how many prescriptions any given
physician writes for any given drug. So Eli Lilly could sponsor Dr. Smith from Detroit or
Manchester, send him to Berlin, and then monitor his prescribing pattern following the
congress. If Dr. Smith's prescriptions for Zyprexa and Prozac do not increase
sufficiently, a company representative can remind him how well he was treated in Berlin.
And besides, isn't he interested in going to Copenhagen next summer?
There is clear evidence that attending conferences such as the 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-expenses paid" symposia at "popular Sunbelt
vacation sites." The company tracked the physicians' prescribing patterns for two drugs,
for 22 months before and 17 months after the symposia.
|Though the physicians had predicted that their attendance
would not affect their prescribing practices, their prescriptions for one drug increased 87
percent and for the other, 272 percent. Other studies have shown that attending drug-sponsored
education courses affects drug-prescribing practices, even though the physicians deny it.
Indeed, if it 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 evaluate schizophrenia drugs are not told
that the expert who minimizes the side effects of Zyprexa receives a $10,000 retainer from
Eli Lilly and also owns substantial company stock. Or that the psychiatric expert claiming
that Remeron reverses depression more rapidly in suicidal patients receives $75,000 per
year from Organon to support his laboratory.
Second, the hoopla adds to the cost of drugs. Payments to aura interpreters and dancing
girls are simply passed on to patients. The pharmaceutical company costs for the Berlin
congress were at least $10 million. According to a recent report, in 2000 the 11
pharmaceutical firms in the Fortune 500 "devoted nearly three times as much of their
revenue to marketing and administrative costs (30 percent of revenue) as to research and
development (12 percent of revenue)."
Plainly some changes are in order. Reform should start with medical 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 largesse of drug companies."
Pharmaceutical companies should be banned from giving gifts to medical students and
residents; the free pizza from the drug representative may seem trivial, 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, not from drug
"detail" (marketing) persons and industry-sponsored talks. Vermont has just made a modest
beginning with a law requiring disclosure of all drug-company gifts to doctors valued at
more than $25. The profession's ethical standards should prohibit experts who are involved
in drug trials or giving talks at symposia from owning stock in pharmaceutical companies.
Unfortunately, most of the profession's organizations, such as the American Psychiatric
Association, are themselves so indebted to drug companies that they are unlikely to lead
For speakers at symposia such as the Berlin meeting, the solution is simple. Prominently
displayed next to the speaker's lectern should be a sign reading: "For this talk, Dr.
Smith is being paid $3,500, business-class airfare, and four-star hotel accommodations by
Eli Lilly and Company."
E. Fuller Torrey