Wednesday, September 07, 2011

The Carlat Blog just got WAY more interesting

A reader writes,

Dear Doctor: Now that CGS (Complicated Grief Syndrome) is the hot new psychosis, are there any neat drugs in the pipeline with cool side effects?

Inquiring junkies want to know.


Dear Reader,

Thanks for your missive. The sad fact is that the psychiatric drug pipeline is flowing at a trickle these days. There's not much that's novel; most new drugs are either tweaks on existing drugs or "me-too" drugs in the same family as existing drugs. As one commenter in one of my favorite blogs recently observed, most new psych meds introduced since 1987 have been a clone of either Prozac (SSRI class antidepressant) or Clozaril ("atypical" antipsychotic).

I've found the recent entries on said blog very interesting. Not sure if you guys will enjoy this discussion as much as I have, but for the curious, here's the back story.

Blog author Daniel Carlat (mentioned here previously) is a psychiatrist in the Boston area who has taken up the noble cause of getting the pharmaceutical industry out of the continuing medical education (CME) business. Up until now, there's been a lot of CME programs that were sponsored by "Big Pharma", to use the somewhat pejorative term. Such programs, unsurprisingly, cast the product(s) of the sponsor in a positive light, making it hard to tell how much of the content was objective and how much was "spin" or bias.

Carlat is not alone in his quest. A lot of medical schools have done away with the old practice of industry-sponsored Grand Rounds, drug lunches, drug dinners, and, in some cases, visits from drug reps entirely. The AMA is starting to voice its concerns as well.

Carlat is, however, one of the more vocal critics of Big Pharma, leading to
this recent response by Stephen Stahl. Dr. Stahl is a psychiatrist and educator. He is on the faculty at UC San Diego and has his own Neuroscience Education Institute, through which he offers CME at symposia around the country. He is also a paid consultant/speaker/researcher for just about every pharmaceutical company - over a dozen of them. So if anybody is qualified to be the opposition in this argument, it's him.

So Dr. Stahl has taken up the fight against the influence of Dr. Carlat and others, calling him a "Pharma-scold" and alleging that, because of people like him, the pipelines are drying up. It's quite a leap, to me, to draw that conclusion, and, I must say, Dr. Stahl's response seemed quite over-the-top, as did the later followup by his minion associate, Debbi Ann Morrissette, PhD.

My take on the whole thing is that Carlat has a genuine concern. When I was in medical school and residency, one of the popular games at Grand Rounds was "Guess The Sponsor". It was an easy game, usually over within five minutes. That was about how long it took to introduce the subject matter and begin talking about the studies that showed how drug X was a good choice for the disease under discussion. Bipolar disorder with rapid cycling? Depakote is good for that. Hey, the guys in the back row are wearing Abbott Labs name tags. I win a free breakfast!

The other side of the coin is that, as far I can tell via the literature and my own clinical experience, Depakote is really the best drug for that condition, so "Big Pharma" has gotten out a message that will help me help patients. And Abbott did disclose that they were the sponsors of the Grand Rounds. And, well, this is America, where capitalism encourages the companies to promote their products, generate sales, and generate profit. The hope is that the profit is married to real benefit for patients, not just the shareholders and those in the company who get bonuses for sales.