Pharmaceutical company advertising in The Lancet

The Lancet, Volume 378, Issue 9785, Page 30
Geoffrey Spurling, Peter Mansfield, Geoffrey Spurling, Peter Mansfield, Joel Lexchin

 

The Editor of The Lancet, Richard Horton, is famously quoted as saying: “Journals have devolved into information laundering operations for the pharmaceutical industry.”1 This sentiment is echoed by former New England Journal of Medicine Editor, Marcia Angell, who describes information from the pharmaceutical industry as coming, “mixed with hyperbole, bias and misinformation, and there is often no way to tell which is which.”2 Both of these statements were cited by the Editors of the Journal of Emergency Medicine Australasia in their decision earlier this year to ban drug company advertising from their journal.3

 

We published a systematic review of 40 years of scientific literature dealing with the effect of information from pharmaceutical companies on physicians' prescribing.4 Some studies found that journal advertisements were more strongly associated with prescribing than the scientific articles in the same journals; others found advertising associated with less rational prescribing and greater prescribing costs. However, none found associations between exposure to journal advertisements and improved quality of prescribing, reduced cost, or reduced prescribing overall.4

 

Our review was published in PLoS Medicine—a top-tier medical journal that does not accept pharmaceutical advertising. The Editors' summary of our review concluded that “the findings support the case for reforms to reduce negative influence to prescribing from pharmaceutical promotion.”

 

Is The Lancet prepared to take a stand against drug company advertisements similar to the Journal of Emergency Medicine Australasia?

 

We declare that we have no conflicts of interest.

 

References

1 Horton R. The dawn of McScience. New York Review of Books 2004; 51: 7. PubMed

2 Angell M. The truth about the drug companies: how they deceive us and what to do about it. New York: Random House, 2004.

3 Jelinek GA, Brown AF. A stand against drug company advertising. Emerg Med Australas 2011; 23: 4-6. CrossRef | PubMed

4 Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med 2010; 7: e1000352.

Psychiatrists Sanctioned over Consulting Fees

By Liz Kowalczyk

Boston Globe Staff

Concluding a three-year investigation, Massachusetts General Hospital and Harvard Medical School sanctioned renowned child psychiatrist Dr. Joseph Biederman and two colleagues after finding they violated conflict of interest rules.

In a letter to coworkers yesterday, Biederman and Drs. Thomas Spencer and Timothy Wilens said the hospital and medical school “have determined that we violated certain requirements’’ of the institutions’ policies.

They did not specify the nature of the violations. But in 2008, Senator Charles Grassley, an Iowa Republican, accused the three doctors of accepting millions of dollars in consulting fees from drug makers from 2000 to 2007, and of failing for years to report much of the income to university officials.

Officials at Harvard and Mass. General released the letter to the Globe, but would not answer questions about the probe. Biederman, Spencer, Wilens, and their lawyers did not return phone calls and e-mails. Grassley’s office did not return calls seeking comment.

Physicians are required to disclose payments from pharmaceutical and medical device companies so that hospital and university officials can police potential conflicts of interest that may create bias in research or in the treatment of patients, or the appearance of bias.

Grassley’s investigation sparked the Mass. General and Harvard inquiries.

The three psychiatrists apologized in their letter for the “unfavorable attention that this matter has brought to these two institutions.’’ They called their mistakes “honest ones’’ but said they “now recognize that we should have devoted more time and attention to the detailed requirements of these policies and to their underlying objectives.’’

They said the institutions imposed remedial actions, requiring them to refrain from all paid industry-sponsored outside activities for one year, with an additional two-year monitoring period during which they must obtain approval before engaging in paid activities. They were also required to undergo unspecified additional training and suffer “a delay of consideration for promotion or advancement.’’

Physicians said it is difficult to know if the sanctions are appropriate without knowing the Harvard and Mass. General findings.

“It’s hard for me to make that judgment, but this all sounds like a little slap on the wrist,’’ said Dr. Jerome Kassirer, a Tufts University School of Medicine professor and outspoken critic of close ties between the drug industry and physicians. He pointed out that Biederman is a full professor at Harvard Medical School, so it’s unclear how a delay in promotion or advancement would affect him. Also, Biederman severed his industry ties soon after Mass. General and Harvard began their separate but coordinated investigations.

The rest of the story can be found here.

A War Inside: Saving Veterans from Suicide

From Penn Medicine

PHILADELPHIA — An estimated 18 American military veterans take their own lives every day -- thousands each year -- and those numbers are steadily increasing. Even after weathering the stresses of military life and the terrors of combat, these soldiers find themselves overwhelmed by the transition back into civilian life. Many have already survived one suicide attempt, but never received the extra help and support they needed, with tragic results. A team of researchers from the Perelman School of Medicine at the University of Pennsylvania and colleagues found that veterans who are repeat suicide attempters suffer significantly greater mortality rates due to suicide compared to both military and civilian peers. The research was published this month in BMC Public Health.

The study is the largest follow-up of suicide attempters in any group in the United States, and is unique even among the relatively few studies on veteran suicide: "We looked at suicide among veterans who had already attempted suicide one time," notes study author Douglas J. Wiebe, PhD, assistant professor of Epidemiology. The findings, he says, "should have us very concerned about current veterans in the more contemporary era."

Wiebe, along with Janet Weiner of Penn's Leonard Davis Institute of Health Economics and Therese S. Richmond of the School of Nursing, teamed with Joseph Conigliaro of the New York University School of Medicine to conduct a study of military veterans who received inpatient treatment at a Department of Veterans Affairs (VA) medical center for a suicide attempt between 1993 and 1998. Using additional data from the VA, as well as the National Center of Health Statistics, these veterans were followed for incidence, rate, and cause of mortality through the end of 2002.

Among the total of 10,163 veterans treated for a suicide attempt between 1993-1998, 1,836 died during the follow-up period through 2002, with heart disease, cancer, accidents, and suicide accounting for over 57% of those deaths. Suicide, however, was the second- leading cause of death among the male veterans, and the leading cause among females, accounting for just over 13% of all the deaths in the study cohort. In comparison, suicide accounted for only 1.8% of deaths in the general U.S. population during those years.

Wiebe and his colleagues discovered that veterans who have attempted suicide not only have an elevated risk of further suicide attempts, but face mortality risks from all causes at a rate three times greater than the general population. The so-called "healthy soldier effect," that military personnel should be healthier than an average person of the same sex and age because they have passed military fitness requirements, does not protect veterans from death from chronic disease, and does not appear to mitigate their risk of suicide. "The 'healthy soldier effect' is no reason to think that veterans should be more emotionally and mentally resilient than anyone else," says Wiebe. "The consequences of military service can include both physical and emotional health challenges that veterans continue to face long after their 'war' is no longer on the front page."

The current study strongly emphasizes the increased need for more intensive and vigorous efforts to identify and support veterans who are at risk, especially those who have already actually attempted suicide, say the authors. With military personnel now facing combat in numbers not seen since the Vietnam War, developing better strategies for suicide prevention is more important than ever. "Almost all of today's soldiers are seeing combat and repeated tours, so that could be a reason to be even more concerned about veteran populations in the years moving forward," Wiebe says.

Wiebe's next step is to analyze the collected data to identify more specific risk factors for suicide or other premature causes of death. Although he argues that "we need to be more tuned into this problem in America in general," he is hopeful that examples of successful suicide prevention programs, particularly one conducted by the U.S. Air Force, could provide an inspiration and foundation for new efforts. "A major part of the success of that program was just changing the climate around how people think and talk about suicide," he says. "There's evidence out there to suggest that could work among veterans too. The time to get started is now."

Dealing With the Depressed or Dangerous

SAN FRANCISCO — How far can colleges go to stop students who are threatening to commit suicide?

It’s a fundamental question for college and university officials who work in the fields of student affairs, counseling and mental health -- and for the lawyers who may have to deal with the aftermath, and sometimes see mental health issues as a minefield of potential litigation.

At a session Tuesday here at the annual meeting of the National Association of College and University Attorneys, experts in legal affairs and mental health urged colleges to do all they can to get students who are threatening to harm themselves into treatment, or to get them off campus if the situation continues to deteriorate.

In the past decade, the number of college students with severe mental health issues has climbed. The development is often attributed to better early intervention and psychiatric drugs that enable students to function normally and attend college who wouldn’t have been able to do so in the past. “That’s a wonderful thing,” said Paul Lannon, an outside lawyer for several New England colleges who moderated the session.

But the increase has also been accompanied by several high-profile lawsuits, and the conclusion colleges and universities draw from those could be “damned if you do, damned if you don’t.”

After a Massachusetts Institute of Technology sophomore, Elizabeth Shin, committed suicide by setting her dorm room on fire in 2000, her family sued MIT for $28 million. They argued that the university’s counseling system failed Shin, who had a documented history of depression and threats before she killed herself. The suit was eventually settled confidentially.

In 2006, Jordan Nott, a former student, sued George Washington University, claiming that he had been forced to withdraw from the university after seeking help for depression. Nott also reached a confidential settlement.

The federal government has intervened in some similar cases through complaints students filed with the Department of Education’s Office of Civil Rights, which has come out against universities who force students to leave campus because of mental illness, including a case at Bluffton University, in Ohio, in 2004.

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The entire story can be found here.

Thanks to Ken Pope for this article.

Psychologist admits to romance with inmate

Paul Walsh for the Star Tribune

A psychologist had a summertime romance with an inmate she was counseling, the state Board of Psychology determined, prompting the panel to revoke her license for at least 10 years.

In findings released Thursday, the board found that Nicole Holman, 33, of St. Paul, admitted to state Department of Corrections investigators that she and the inmate began their sexual relationship in June 2010 while she was providing therapy to him as part of the chemical dependency program.

While the board's report didn't disclose where Holman worked, state records show that she was at the Lino Lakes prison at the time of the relationship. The name of the inmate also was not disclosed.

According to the board:

Holman and the inmate "engaged in sexually explicit dialogue" in telephone conversations last summer. One call refers to the inmate "spanking" Holman. Two other calls refer to when the inmate exposed himself to Holman, "presumably during a therapeutic session."

In a three-week period from late July to mid-August, the inmate called Holman's cell phone 106 times.

Holman can apply to have her license restored in 10 years.

Prior to working with the Department of Corrections, Holman was employed with Hennepin County as a child-protection social worker, according to county records.

A telephone message was left Thursday afternoon with Holman seeking a reaction to the board's ruling.

Vignette 4: A Psychologist in Turmoil

Vignette 4

A psychologist is treating a client who is involved in a legal proceeding.  The client presents the psychologist with information about a well-known, local psychologist who released confidential information to an attorney without a signed release or court order.  After the psychologist reviews the information presented, it is clear to the treating psychologist that other psychologist breached confidentiality.

The treating psychologist knows the local psychologist who released the information, but does not have a strong relationship with him.  The treating psychologist is questioning what to do.  The treating psychologist believes the options are:

1. Address the matter with the other psychologist directly.

2. Refer the matter to the State Board of Psychology.

3. Encourage the client to file a complaint with the State Board of Psychology.


Are there any other options?

What are the possible emotional reactions to this situation?  And, how would you, as the treating psychologist, deal with those emotions?

What is a likely course of action?

Loughner forced medication OKd by judge

From the San Francisco Chronicle

A judge ruled Wednesday that prison officials can forcibly give the man accused of the Tucson shooting rampage antipsychotic drugs in a bid to make him mentally fit for trial.

U.S. District Judge Larry Burns' decision came after Jared Lee Loughner's attorneys filed an emergency request last week to prevent any forced medication of their client without approval from a judge. The judge said he did not want to second guess doctors at the federal prison in Springfield, Mo., who determined that Loughner was a danger.

"I have no reason to disagree with the doctors here," Burns said. "They labor in this vineyard every day."

Loughner, who was not at the hearing in San Diego, has been at the Missouri facility since May 28 after the judge concluded he was mentally unfit to stand trial and help in his legal defense.

Mental health experts had determined the 22-year-old college dropout suffers from schizophrenia and will try to make him psychologically fit to stand trial. He will spend up to four months at the facility.

Prosecutors have argued that Loughner should be given antipsychotic drugs because he has been diagnosed as schizophrenic and poses a danger to others.

"This is a person who is a ticking time bomb," prosecutor Wallace Kleindienst said Wednesday.

In a filing Tuesday, prosecutors cited an April 4 incident where Loughner spit on his own attorney, lunged at her and had to be restrained by prison staff. They also cited an outburst during a March 28 interview with a mental health expert in which Loughner became enraged, cursed at her and threw a plastic chair at her twice.

Loughner has pleaded not guilty to 49 charges stemming from the Jan. 8 shooting that injured Rep. Gabrielle Giffords and 12 others and killed six people, including John Roll, the chief federal judge for Arizona.

If Loughner is later determined to be competent enough to understand the case against him and assist his lawyers, the court proceedings will resume.

Living the Good Lie

By Mimi Swartz

The New York Times Magazine

Denis Flanigan isn’t hiding anything. A 42-year-old psychotherapist in Houston, he has a straightforward manner that meshes nicely with his no-nonsense buzz cut and neatly clipped goatee. Unlike many mental-health professionals, Flanigan puts personal items on display in his office, including a photo of his partner, who is attractive, and male. For his patients’ amusement he has on hand an S-and-M Barbie as well as a Tickle Me Freud doll. (“It’s so, so . . . wrong,” Flanigan told me, in a tone that signaled he believed it was exactly right.) Flanigan’s no-secrets policy extends to his Web site, where he writes that he “has frequently been asked to speak on the gay and lesbian experience and mental health, transgender concerns and body-modification issues.” A member of the American Psychiatric Association, Flanigan has also served as Mr. Prime Choice Texas, winning a contest “designed for men 40 years or older who represent the masculine aesthetic embraced by the leather/Levi/uniform/fetish community.” In his own words, he identifies as a “militant homosexual.”

So it comes as a bit of a surprise to learn that when potential clients come to Flanigan’s office to discuss their sexual orientation — in particular whether they should reveal their homosexuality to friends, family or employers — his first response is to ask, in a neutral tone, “Why do you want to do that?” Flanigan has a 20-year history of gay activism behind him, so you might expect that his primary goal would be to help gay clients discover and cultivate their most authentic selves. As Jonathan Ned Katz wrote in “Gay American History” in 1976, “Therapists who do not help their homosexual patients to fully explore the possibility of homosexuality as a legitimate option have not helped to expand those individuals’ freedom.”

Flanigan doesn’t disagree with Katz. “I’m a very strong believer in people’s rights,” he said one gray morning at a Starbucks in Houston. But during his early training, he encountered a few clients who either would not come out of the closet or suffered mightily when they did. Christians of the kind who earnestly believed that the Bible deplored homosexuality were particularly troubled as they tried to reconcile their faith with their sexual orientation. The more Flanigan studied this conundrum, the more he came to see it as intractable. Some gay evangelicals truly believe that to follow their sexual orientation means abandonment by a church that provides them with emotional and social sustenance — not to mention eternal damnation. Keeping their sexual orientation a secret, however, means giving up any opportunity to have fulfilling relationships as gay men and women.

“When these clash, what do you do?” Flanigan recalled thinking, and when he began to research the topic about a decade ago, he found few answers beyond the obvious. Antigay religious groups would not condone homosexuality; they thought gays should just give up their orientation, and the most extreme among them offered frightening “conversion” practices. Nonreligious gays thought the conflicted should just walk away from churches that won’t accept homosexuals as they are. “Which trumps which?” Flanigan asked himself. “Religion or sexual orientation?”

The entire article can be found here.

Nurse's suicide highlights twin tragedies of medical errors

by JoNel Aleccia

Health writer - msnbc.com

For registered nurse Kimberly Hiatt, the horror began last Sept. 14, the moment she realized she’d overdosed a fragile baby with 10 times too much medication.

Stunned, she told nearby staff at the Cardiac Intensive Care Unit at Seattle Children’s Hospital what had happened. “It was in the line of, ‘Oh my God, I have given too much calcium,’” recalled a fellow nurse, Michelle Asplin, in a statement to state investigators.

In Hiatt’s 24-year career, all of it at Seattle Children’s, dispensing 1.4 grams of calcium chloride — instead of the correct dose of 140 milligrams — was the only serious medical mistake she’d ever made, public investigation records show.

“She was devastated, just devastated,” said Lyn Hiatt, 49, of Seattle, Kim’s partner and co-parent of their two children, Eli, 18, and Sydney, 16.

That mistake turned out to be the beginning of an unraveled life, contributing not only to the death of the child, 8-month-old Kaia Zautner, but also to Hiatt’s firing, a state nursing commission investigation — and Hiatt's suicide on April 3 at age 50.

Hiatt’s dismissal — and her death — raise larger questions about the impact of errors on providers, the so-called “second victims” of medical mistakes. That’s a phrase coined a decade ago by Dr. Albert Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

It’s meant to describe the twin casualties caused by a serious medical mistake: The first victim is the patient, the person hurt or killed by a preventable error — but the second victim is the person who has to live with the aftermath of making it.

No question, the patients are the top concern in a nation where 1 in 7 Medicare patients experience serious harm because of medical errors and hospital infections each year, and 180,000 patients die, according to a November 2010 study by the Department of Health and Human Services’ Office of Inspector General.

That’s nearly double the 98,000 deaths attributed to preventable errors in the pivotal 2000 report “To Err is Human,” by the Institute of Medicine, which galvanized the nation's patient safety movement.

In reality, though, the doctors, nurses and other medical workers who commit errors are often traumatized as well, with reactions that range from anxiety and sleeping problems to doubt about their professional abilities — and thoughts of suicide, according to two recent studies.

Surgeons who believed they made medical errors were more than three times as likely to have considered suicide as those who didn’t, according to a January survey of more nearly 8,000 participants published in the Archives of Surgery.

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 The entire story can be found here.