Psychiatrists become drug firms' targets

By Ellen Barry, Boston Globe Staff, 5/28/2002

PHILADELPHIA - Ivonne Munez Velazquez, a psychiatrist from Mexico, rooted through her goody bag like a child on Halloween.

As a reward for attending the American Psychiatric Association's annual meeting, she had received a small egg-shaped clock from the makers of the antidepressant Prozac; a sleek thermos from Paxil, also an antidepressant; and an engraved silver business card holder courtesy of Depakote, an anticonvulsant. She got a neat little CD carrying case from Risperdol, an antipsychotic; a passport holder from Celexa, an antipsychotic; a neat green paperweight from Remeron, an antidepressant; and a letter opener, representing what drug she could not remember.

For the duration of the weekend, though, Velazquez's loyalty belonged to Pfizer, which had paid her airfare from Mexico City (along with 30 of her colleagues and her 18-year-old nephew) and put them all up in hotels near the APA meeting. That night, also courtesy of Pfizer, she would attend a glittering banquet at the Philadelphia Academy of Fine Arts. Asked whose products she prescribes the most, Velazquez giggled, looked around and whispered, ''Lilly.''

In psychiatry, as in all branches of medicine, this extravaganza of marketing has become so familiar as to be almost invisible. Nearly every specialist attending a conference can expect to receive a portion of the $13 billion to $15 billion that pharmaceutical companies are likely to spend on marketing this year. With central nervous system medications now making up almost a quarter of sales, and newly defined illnesses such as social anxiety disorder calling for a new round of prescribing, psychiatrists have become a particular target.

Unlike surgeons, however, psychiatrists are in the habit of examining behavior, including their own, and several sessions last week were devoted to the issue of free gifts. A Brooklyn psychiatrist presented a new paper titled ''Attitudes of Physicians Towards Gifts from the Pharmaceutical Industry: A Pilot Study.'' A symposium asked ''Psychiatry and the Pharmaceutical Industry: Where Is the Boundary?'' and the APA's Committee on Commercial Support invited dissidents in for a discussion called ''The Pharmaceutical Industry and the APA: Controversies and Approaches.'' As his colleagues lined up to express their outrage at the influence of industry on the meeting, Stephen Goldfinger, chairman of the committee, listened sympathetically.

''Look, my politics are such that I would nationalize the health-care system and switch to a single-payer system,'' Goldfinger said. ''This country has said we believe in the entrepreneurial model, in capitalism. The pharmaceutical companies are an amoral bunch.

''They're not a benevolent association. So, they are highly unlikely to donate large amounts of money without strings attached. Once one is dancing with the devil, you don't always get to call the steps of the dance.''

And with APA dues proceeds falling every year, dancing they were. Drug companies paid between $200,000 to $400,000 apiece - plus a $60,000 direct payment to the APA - for each of 50-plus ''industry-supported symposia,'' in which doctors ate in banquet halls and listened for three hours to industry-sponsored speakers, Goldfinger said. The shuttle buses to and from hotels were underwritten by AstraZeneca; Pfizer brought in Sylvia Nasar, author of ''A Beautiful Mind,'' and passed out free copies of her book; and a relaxing Zen garden was paid for by Solvay Pharmaceuticals.

Without the drug company money, officials said, the annual meeting would lose educational benefits along with amenities.

''How much are you willing to pay for that, if we don't accept drug company money?'' said Anand Pandya, who reviews new research for the APA meeting. ''Are you willing to pay $3,000?'' Dues are now $540.

Much of the gift-giving in evidence last week will actually be prohibited next year under new regulations self-imposed by the pharmaceutical industry. Starting July 1, it will be illegal to offer doctors pure entertainment - such as a Forest Pharmaceuticals-sponsored concert by the blues artist Keb' Mo' - or pay travel expenses for nonfaculty health-care professionals. Branded golf balls will be prohibited, as they ''do not primarily entail a benefit to patients,'' and drug representatives will no longer be allowed to pay to fill doctors' cars with gasoline.

Reformers within medicine, however, would like to see the restraint coming from the doctors.

''You would sort of expect it from orthopedic surgeons, all those former athletes, but psychiatrists are supposed to be the philosophers of medicine, the thinkers,'' said Bob Goodman, a New York internist who founded the organization, No Free Lunch, which urges doctors to refuse freebies of any kind. ''You don't expect to see them fighting over those cheesy little gifts.''

For those psychiatrists who have taken up that gauntlet, the convention can be an uncomfortable place. Richard Roston, a fourth-year resident in New Mexico, attended the APA convention for the first time two years ago, and was astounded at what he described as a ''pharmaceutical theme park.''

Since then, he has taken Goodman's pledge of complete abstinence from free gifts. This has resulted in a degree of isolation, he said.

''When you don't eat lunch, you're thought of as being holier than thou,'' Roston said. ''But that's how all social movements start. They ignore you and they ridicule you and then they start listening to you. This is somewhere between ignore and ridicule.''

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