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Dancing with the Devil? A personal view of psychiatry's relationships with the pharmaceutical industry

  • Mike Shooter (a1)
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Dancing with the Devil? A personal view of psychiatry's relationships with the pharmaceutical industry

  • Mike Shooter (a1)
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Pharmaceutical companies and psychiatrists in developing countries: Pakistan

Murad M Khan, Professor of Psychiatry
25 April 2005

I would largely agree with Mike Shooter’s patient that `you are all in the pockets of drug companies’. I am sure the President could not have helped noticing the large numbers of British psychiatrists at the recentlyheld World Psychiatric Association Regional meeting in Lahore, Pakistan inSeptember 2004. I wonder if he knew almost all of them had been sponsored by pharmaceutical companies. />
In developing countries like Pakistan, the mutually exploitative relationship between pharmaceutical companies and psychiatrists is causingabsolute havoc in health care. There is neither health insurance nor a viable public funded health system and almost all health care is out-of pocket expenditure. With little or no regulation on either medical practice or the prescribing and dispensing of drugs or on the interaction between physicians and drug companies, both parties are free to act as they deem fit. The enticements Shooter talks about pale into insignificance compared to the inducements on offer for psychiatrists in Pakistan. One of the latest is the putting the down payment for a brand new car for the physician by the company. All the physician has to do is to write 200 prescriptions of the company’s expensive drug.

Today, many developing countries, like Pakistan, are facing a crisis of mental health. While prevalence of common mental disorders are very high, resources- both personnel and financial are severely lacking. More significantly, at the government planning and policy making level, there is neither an understanding nor a political will to change the status quo.Under these circumstances, institutions and individual physicians assume afar more critical role than in countries with well developed health systems. Both need to be cognisant of the enormous responsibility they carry in dealing with the poor, the ill and the distressed in these settings.

Above all there is a need to get away from the culture of greed and profit, the same factors that drives the corporate world, which appears tohave pervaded the psychiatric profession in Pakistan. The medical profession in general but psychiatrists in particular need to take a hard,deep look and ask themselves why have they been so willing to bargain awaytheir integrity for a few thousand rupees. They would do well to remind themselves that `once you have sold your soul, it can be a hard item to retrieve’. (Jung, 2000)

Jung P. (2002) No free lunch. Health Affairs, 21:2: 226-231. ... More

Conflict of interest: None Declared

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Pharmaceutical industry and developing countries-Sri Lanka

Lalith A. Kuruppuarachchi,MD, MRCPsych ( U.K.), Professor of Psychiatry,
25 April 2005

Sir: It is with interest that we read your editorial "Dancing with the Devil? A personal view of psychiatry's relationship with the pharmaceutical industry" (1) as we feel it has much relevance to developing countries such as Sri Lanka. It appears that the pharmaceuticalindustry deploy methods of which the nature and quality are different whendealing with our countries, such as poor detailing of products which sometimes lead to deleterious effects.

The pharmaceutical industry and the medical profession mainly interact through the sales promotion of drugs and symposia organised by pharmaceutical companies in our countries.The industry influences prescribing patterns through drug promotion and other methods and if such interactions are transparent and doctors are able to deflect undesirable influences on their prescribing habits, no impropriety will be alleged (2).

Large scale commercial trials are still not conducted in Sri Lanka though help is often given informally, either monetary or equipment. But there is a possibility that will change as more companies are looking towards developing countries to carry out clinical trials because of the low cost and availability of human resources.

It has been shown that research funded by pharmaceutical companies are less likely to be published and more likely to have out comes favourable to the sponsor (3). Nevertheless, the interaction between academia and the pharmaceutical industry is valuable and should be perfected with academically based bodies regulating them (4).

In many developing countries clinicians rely on chemotherapy more than in the west due to a shortage of human resources. Therefore, time consuming psychological therapies are rarely used.

However, though psychiatrists in developing countries may be more vulnerable to undue influence exerted by pharmaceutical companies, we believe that the governing ethical principle that our primary obligation is to the patient will guide us to be independent and help us conform to rational prescribing practices.

References1.Shooter, M. (2005). Dancing with the Devil? A personal view of psychiatry's relationships with the pharmaceutical industry. Psychiatric Bulletin 29:81-83.2.Breen, K.J. (2004). The medical profession and the pharmaceutical industry: when will we open our eyes? Medical Journal of Australia, 180 (8): 409-410.3.Lexchin, J., Bero, L.A., Djulbegovic,B., et al (2003) Pharmaceutical industry sponsorship and research outcome and quality: systematic review. British Medical Journal, 326:1167-1170.4.Montaner, J.S.G., O'Shaughnessy, M.V., Schechter, M.T. (2001) Industry-sponsored clinical research: a double-edged sword. The Lancet, 358:1893-1895.
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Conflict of interest: None Declared

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Relationship with the Pharmaceutical companies-Solutions to the problem

Pavan S Chahl, Staff Grade Psychiatrist
22 March 2005

The article ‘Dancing with the Devil-Mike Shooter’ is very relevant toPsychiatric Practice today. For me it raises two very important issues. What should we be telling Trainees about evidence presented to them by Pharmaceutical companies and what are Psychiatrists to do when every time a referral is made for Psychological interventions we are told-‘the patient has been placed on the waiting list’ or ‘there is no psychologist working with the team at the present time’.

Meeting a medical representative can be a very fruitless exercise at the best of times. We tend to be very cynical about the evidence being presented to us and it is not possible to critically appraise the evidencebeing presented to us in fifteen minutes. The best way for Trainees to understand the evidence presented to them is to Critically Appraise these very papers presented to them at their respective Journal clubs.

With regard to psychological interventions; there is an acute shortage of staff trained in different Psychotherapeutic modalities. Thereneeds to be a greater push towards making training in Psychotherapy compulsory for both Senior House Officers and nursing Staff. This will allow us to make better use of the existing professionals in different Trusts rather than spending far more on hiring new staff. This will also decrease the pressure on using medications for the management of Psycho-Social problems.
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The 'Devil' does not always lead the dance

susanne McCabe, retired
09 March 2005

A couple of years ago I wrote to the recent past President to raise concerns about reports in the media about his failure to declare his shareholdings in a Drugs Company -when he was sitting on a DoH Committee which considered the use of prescribed drugs in the NHS. He was not contesting this. I received no reply. Is it ethical or indeed simply sensible for anybody with any self interest to sit on such a Committee?The College may benefit from having an independant group of people to advise on such matters as there have been similar difficulties, such as the acceptance of funding from BAT (British American Tobacco)to carry out research into brain disease at the Institute of Psychiatry. In this case I had no reply again to a letter sent to the College but did receive a letter from the lead researcher who defended the action on the grounds of it being 'for the greater good'. Although his response is flawed as born out by the position of Government regarding BAT now, he was willing to debate his opinion. ... More

Conflict of interest: None Declared

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Belief in the pharmaceutical industry

D B Double, Consultant Psychiatrist
07 March 2005

I welcome Mike Shooter's attempts as President of the Royal College of Psychiatrists to tighten the guidelines on sponsorship by the pharmaceutical companies. His editorial (Shooter, 2005) on the relationship between psychiatry and the industry suggests we have to accept that drugs do help. However, the example he gives of phenothiazines producing dehospitalisation may not make his point very well. Mental hospital bed numbers were reducing before the introduction of chlorpromazine and Aubrey Lewis (1959) famously said "If we had to choose between abandoning the new psychotropic drugs and abandoning the industrial rehabilitation units and other social facilities available to us, there would be no hesitation about the choice: the drugs would go." Nor have neuroleptics prevented the reinstitutionalisation that has occurred in mental health care over recent years (Priebe & Turner, 2003).Shooter also comments on doctors' failing to recognise adverse effects of medication. One of the most pertinent examples is the dramatic change in advice about discontinuation reactions with antidepressants. A key message of the Defeat Depression Campaign of the Royal Colleges of Psychiatrists and General Practitioners was that patients should be informed clearly when first prescribed antidepressants that discontinuing treatment in due course will not be a problem (Priest et al, 1996). Just eight years later the National Institute for Clinical Excellence (2004) advises that patients prescribed antidepressants should be given a disclaimer about the risk of discontinuation/withdrawal symptoms.A common belief is that psychotropic medication corrects chemical imbalances in the brain. Psychiatrists will be accused of being "pill-pushers" and "in the pocket of the drug companies" until they become more sceptical about this claim.LEWIS, A, (1959) Response to Brill. In: P. Bradley & P. Deniker (eds) Neuropharmacology. Amsterdam: Elsevier PressNATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004) Management of depression in primary and secondary care. (Clinical guideline 23) London: NICE PRIEBE, S. & TURNER, T. (2003) Reinstituitonalisation in mental health care. BMJ, 326, 175-176PRIEST, R.G., VIZE, C., ROBERTS, A., ROBERTS, M. & TYLEE, A. (1996) Lay people's attitude to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ, 313, 858-859SHOOTER, M. (2005) Dancing with the Devil? A personal view of psychiatry's relationship with the pharmaceutical industry. Psychiatric Bulletin, 28, 81-83 ... More

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