When conflicts of interest arise in medicine
ANALYSIS:Is our approach to mental health compromised by the drugs industry’s financial ties with health professionals?
THE GLOSSY health brochure and website look innocuous enough.
“Solutions for Wellness”, it says, along with information on nutrition, wellness and maintaining a healthy lifestyle. It’s a programme being rolled out by health professionals in many mental health services across the country.
There is no mention of drugs of any kind – until you notice the programme itself is sponsored by drug manufacturer Eli Lilly, the makers of some of the most commonly prescribed mental health drugs such as Prozac and Zyprexa.
It’s something which makes Agnes Higgins – an associate professor in mental health at Trinity College Dublin’s school of nursing – feel uncomfortable.
“This is information which has been created by a pharmaceutical company and carries their logo. We are supposed to be providing impartial advice and support to patients. Should we be uncritically accepting or distributing this information?”
For many, it is part of a worrying trend in recent years in which drug companies are playing a more active role in sponsoring medical events, research and education, potentially compromising the independence of nurses and doctors.
Patient groups and growing numbers of health professionals fear the boundaries between education and promotion are becoming increasingly blurred, while patients can be left in the dark over the true value of medication.
Mental health medication is big business. The number of prescriptions on the medical card in Ireland have increased by more than 25 per cent between 2006 and 2010, costing the State in excess of €100 million. This figure does not include private prescriptions, which would push the overall value of the market higher still.
The industry insists there are measures in place to ensure marketing material provides accurate and unbiased information on drugs. The Irish Pharmaceutical Healthcare Association points to codes of conduct to guarantee ethical behaviour.
As far as information leaflets or advertisements are concerned, the association says these campaigns help the wider public.
“Pharmaceutical companies are well within their rights to support awareness campaigns on health matters, provided they do not mention or endorse individual products,” an association spokesman said.
“The IPHA is very active in keeping member companies apprised of their obligations in this regard”.
Despite these safeguards, the industry has been at the centre of numerous scandals over recent years over the exaggerated benefits of drugs, or withholding information on potentially harmful side-effects.
Drug regulators, such as the Irish Medicines Board (IMB), have faced criticism for being close to the industry. In a study, Dr Orla O’Donovan of UCC’s department of applied social studies, found that the agency restricted public access to information regarding conflicts of interest.
The IMB, however, says members of advisory committees are required to disclose any potential conflict. It says that while these have not been publicly available, this will change.
“It is anticipated that publication of a summary of board member declarations will be completed in the coming weeks. Similar information for IMB senior management will also be published shortly,” a spokeswoman said.
But an even bigger area, say many, are the intersecting circles of education at third level with the drugs industry. In the US, the industry sponsors up to 70 per cent of drug research in academic institutions; similar figures are not available for Ireland, though the industry also plays a central role.
Research commissioned by the Mental Health Commission notes that while this funding can be very useful, the full implications of it need to be considered.
Its research strategy document cites the argument that drug companies have helped create and reinforced a “narrow, biological approach to the explanation and treatment of mental disorders” which has led to the neglect of alternative non-drug based approaches. The documents concluded the industry has a role to play, with appropriate safeguards.
Dr Dermot Walsh, former inspector of mental hospitals, says the relationships between the industry and doctors have much improved in recent years, though there is still a way to go.
He points to the Medical Council’s guidelines on ethical behaviour which state that “doctors should not allow their relationship with commercial firms influence their attitude towards the design or the results of trials”.
Many of these issues were covered in a report by the Oireachtas Joint Committee on Health and Children a few years ago. It recommended a number of changes to make our drug regulation system stronger and more transparent. There has been little progress on fully implementing the findings.
“Many people were encouraged by the report because it gave official recognition for the first time of how conflicts of interest can arise in medicine,” says Dr O’Donovan. “What we would like to do is to reignite that discussion and the implications for public health.”
'I don't believe in the "chemical brain imbalance theory" - yet I felt I was being coerced into taking that drug'
WHEN RICHARD Patterson developed a mental health problem, he went in search of support from a health professional.
He hoped the information he received would be objective – but he couldn’t help feeling he was the marketing target of the pharmaceutical industry.
The leaflet he was given on how to improve his lifestyle was accompanied by the logo of a major pharmaceutical company, which manufactures some of the most commonly prescribed medications for depression and schizophrenia.
Patterson, a critic of the “medical model” of psychiatry who feels drugs are not the answer, felt dismayed.
“I didn’t have any problem with the material regarding the importance to general wellbeing of diet, exercise and stress management,” he says.
“But, because pharmaceutical companies can’t advertise openly, it just serves as a marketing vehicle.”
It’s not the only piece of literature sponsored by the industry he has seen in his time as a patient.
He gives the example of a leaflet on the anti-psychotic drug Zyprexa which made various health-related claims.
“Your doctor has recently prescribed you Zyprexa,” says the leaflet, accompanied by pictures of smiling couples and people out walking. “Congratulations on taking this important step on the road to recovery.”
The company involved, Eli Lilly, pleaded guilty to criminal conduct in the US involving its marketing of Zyprexa, and agreed to pay $1.4 billion in fines.
The charges Lilly was accused of included persuading doctors to prescribe Zyprexa to two categories of patients – children and the elderly – for whom the drug was not approved and in whom its use was especially deemed risky.
All of this has made Patterson question how truly objective many doctors are, and how the influence of drug companies can sometimes seem all-pervasive.
“In my case, the consultant wanted me to take a drug made by the company,” he says. “But, like many people, I don’t believe in the ‘chemical brain imbalance theory’ that underpins medical model-based psychiatry. Yet, I felt I was being coerced into taking that drug.”