The promotion of olanzapine in primary care: An examination of internal industry documents

U.S. physician burnout and the proletarianization of U.S. doctors: A theoretical reframing

We delve into the escalating issue of U.S. physician burnout, arguing its roots lie in the proletarianization of the U.S. medical profession-a transition driven by the loss of autonomy and control under the shadow of capitalist systems. This process, aligned with Marx's concept of proletarianization, sees physicians morph from independent practitioners to exploited workers within a wage-labor system controlled by a corporatized U.S. healthcare system. We contend that contemporary factors attributed to U.S. physician burnout-loss of control, emphasis on productivity, increased clerical demands, and a diminishing sense of work's meaning-are not novel but deeply ingrained in the medical profession's socio-historical fabric. By juxtaposing burnout with proletarianization, we highlight macro-level sources of strain and advocate for reevaluating physician work through Marxist theory and, in turn, extend the argument that addressing burnout necessitates moving beyond individual or organizational solutions to encompass broader socio-economic structures as seen through the lens of work exploitation. We conclude by discussing "class consciousness" among U.S. physicians and posit that collective awareness and action could pave the way for substantial reforms for the practice of medicine, the organization of medicine as a profession, and the burnout epidemic among U.S. physicians.

Tip of the Iceberg? Country- and Company-Level Analysis of Drug Company Payments for Research and Development in Europe

BACKGROUND

Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interest (COIs). We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.

METHODS

Using documentary sources and a stakeholder survey we identified country- regulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the United Kingdom, a country with a major role in Europe's R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.

RESULTS

In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a self-regulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the United Kingdom suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available company-level data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D.

CONCLUSION

The lack of full disclosure of R&D payments in countries with industry self-regulation leaves considerable sums of money unaccounted for and potentially many COIs undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.

Re-Analyzing Phase III Bremelanotide Trials for "Hypoactive Sexual Desire Disorder" in Women

Kingsberg et al. described results from two 24-week Phase III trials of bremelanotide for treating hypoactive sexual desire disorder (HSDD) in women. 72.72% of protocol-listed outcomes were not reported by Kingsberg et al., who provided results of 15 secondary measures which were not listed in the study protocols. None of their efficacy outcomes were reported in line with CONSORT data reporting standards and no secondary outcome had a stated rationale or cited evidence of validity. My meta-analysis of the trials' data, based on the FDA New Drug Application, found similar results to Kingsberg et al. However, Kingsberg et al. did not report that a) adverse event-induced study discontinuation was substantially higher on bremelanotide: OR = 11.98, 95% CI = 3.74-38.37, NNH: 6 or b) participants preferred placebo, measured by the combination of both 1) completing a clinical trial and 2) electing to participate in the follow-up open-label study (OR = 0.30, 95% CI = .24-.38, NNH: 4). Bremelanotide's modest benefits on incompletely reported post-hoc measures of questionable validity in combination with participants substantially preferring to take placebo suggest that the drug is generally not useful. Kingsberg et al.'s data reporting and measurement practices were incomplete and lacked transparency.

Confidentiality Orders and Public Interest in Drug and Medical Device Litigation

Litigation involving drug and medical device manufacturers has the potential to reveal important information about product efficacy and safety as well as company marketing. Prevailing legal standards recognize the public's interest in having access to certain types of information in lawsuits. However, in practice, courts and litigants commonly use overly broad or unwarranted confidentiality orders, which can prevent the public from accessing important public health information that emerges during litigation. This Special Communication reviews the rules governing confidentiality orders and discusses the tension between these rules and prevailing legal practices relating to court secrecy in medical product litigation, including competing interests among manufacturers, plaintiffs, and courts. Using examples of successful efforts to challenge confidentiality orders, we describe how these prevailing legal practices can undermine access to information by patients, clinicians, and the US Food and Drug Administration and also obscure patterns of injury and disease associated with the drugs and medical devices at issue. We then discuss several ways to advance access to information important to public health that emerges during litigation, focusing particularly on the role of medical experts engaged in cases.

Psychotropic prescriptions for the treatment of schizophrenia in an outpatient clinic

INTRODUCTION

There is an unpredictable pattern in the prescription of antipsychotics and other psychotropic medications for the treatment of schizophrenia, particularly in resource-limited settings in developing countries.

OBJECTIVE

To determine the psychotropic prescriptions given to patients with schizophrenia in an outpatient clinic of a tertiary hospital and to describe the choices and trends of these prescriptions.

METHODS

This was a cross-sectional descriptive study of prescriptions for adults with schizophrenia. After clinical consultation, patients' case notes were randomly selected over a period of 2 years. Using a structured form, data were extracted from the case notes including biodemographic data, psychotropic medications prescribed and changes made to these prescriptions. Data were analyzed by means of descriptive statistics.

RESULTS

A total of 103 patients were selected, with a mean age of 35.96±9.78 years; 48.5% were males and 51.5% were females; 33% were unemployed and 38% had been hospitalized in the past. There were 231 initial prescriptions and 228 current prescriptions, with about 2.2 prescriptions per patient. Haloperidol (mean dose 14.77±6.28mg and 11.44±5.55mg for initial and current) and other old-generation antipsychotics were the most commonly prescribed for new cases (98%). Mean duration of psychotropic use was 7.78±5.6 years. All the patients were prescribed trihexyphenidyl, and 56.3% of the patients had their medications changed as a result of side effects.

CONCLUSION

There was a very high preference for the use of first-generation antipsychotics for all treatment settings (in- and outpatients), a pattern that is likely to persist.

Patterns of psychotropic medication use in inpatient and outpatient psychiatric settings in Saudi Arabia

OBJECTIVE

To study the pattern of psychotropic medication use and compare this pattern between inpatient and outpatient psychiatric settings in Saudi Arabia.

METHOD

This cross-sectional observational study was conducted between July 2012 and June 2014 on patients seeking psychiatric advice at major hospitals in five main regions of Saudi Arabia. Male (n=651) and female (n=594) patients who signed the informed consent form and were currently or had been previously using psychotropic medications, irrespective of the patient's type of psychiatric diagnosis and duration of the disease, were included. A total of 1,246 patients were found to be suitable in the inclusion criteria of whom 464 were inpatients while 782 were outpatients.

RESULTS

Several studied demographic factors have shown that compared with outpatients, inpatients were more likely to be male (P=0.004), unmarried (P<0.001), have less number of children (1-3; P=0.002), unemployed (P=0.001), have a lower family income (<3,000 SR; P<0.001), live in rural communities (P<0.001), have a lower body mass index (P=0.001), and are smokers (P<0.001); however, there were no differences with regard to age or educational levels. The current frequency of use of psychotropic medications in overall patients was antipsychotics (76.6%), antidepressants (41.4%), mood stabilizers (27.9%), and antianxiety (6.2%). However, compared to outpatients, the current use of medications for inpatients was more frequent (93.8% vs 89.9%, P=0.019) with inpatients more likely to be treated with multiple medications (2.1 vs 1.8 medications). A similar trend was observed in the case of antipsychotics, high potency first-generation antipsychotics, second-generation antipsychotics, mood stabilizers, and antianxiety medicines where inpatients were more frequently treated with these medications for all psychiatric diagnoses when compared with outpatients. On the contrary, in the case of antidepressant treatment, an opposite trend was observed with more number of treated outpatients in comparison to inpatients. Among elderly patients, 75.9% received antipsychotics, mainly second-generation formulations (67.2%), whereas only 41% received antidepressants and 13.8% received mood stabilizers.

CONCLUSION

Based upon the present study data, it is concluded that among all the psychotropic medications, antipsychotics were heavily used and the frequency was found to be significantly high in the case of inpatients compared with outpatients. Such a practice may lead to multiple negative consequences among the Saudi psychiatric patient population. Further, extensive use of sodium valproate in the case of bipolar disorder, and also among females either in childbearing age or during pregnancy is also the cause of concern and warrants logical use. Overall, this study may help in assessing the burden of psychiatric illness within specific patient demographics and might be effectively used to strategically plan health resources allocation, generate new treatment hypothesis, or be used as a source of evidence that could further integrate other observational studies.

The Ascendancy of Second-Generation Antipsychotics as Frontline Antimanic Agents

INTRODUCTION

Knowledge of the factors affecting the adoption of new medications can enhance mental health care and guide quality improvement and policy development. Food and Drug Administration indications for treating bipolar disorder with several second-generation antipsychotics (SGAs) in the 2000s represent an opportunity to identify factors that impact the spread of a then-innovative treatment through a new population.

METHODS

Analysis of Department of Veterans Affairs administrative data identified the population of 170,811 veterans diagnosed with bipolar disorder from 2003 to 2010. We analyzed time trends and predictors of antimanic choice (SGA vs other) among the 40,512 outpatients with bipolar disorder who initiated their first VA outpatient antimanic prescription, using multinomial logistic regression in month-by-month analyses. We conducted classwise analyses and investigated prespecified predictors among specific agents.

RESULTS

In classwise analyses, SGAs supplanted lithium, valproate, and carbamazepine/oxcarbazepine as the most commonly initiated antimanics by 2007. Psychosis, but not other indices of severity, predicted SGA initiation. Demographic analyses did not identify substantial disparities in initiation of SGAs. Drug-specific analyses revealed some consideration of medical comorbidities in choosing among specific antimanic agents, although effect sizes were small. Most patients initiating an antimanic had received an antidepressant in the previous year.

DISCUSSION

Second-generation antipsychotics quickly became the frontline antimanic treatment for bipolar disorder, although antidepressants most commonly predated antimanic prescriptions. Second-generation antipsychotics were used for a broad range of patients rather than being restricted to a severely ill subpopulation. The modest association of antimanic choice with relevant medical comorbidities suggests that continued attention to quality prescribing practices is warranted.

The medicalisation of "ups and downs": the marketing of the new bipolar disorder

The concept of bipolar disorder has undergone a transformation over the last two decades. Once considered a rare and serious mental disorder, bipolar disorder is being diagnosed with increasing frequency in Europe and North America, and is suggested to replace many other diagnoses. The current article shows how the modern concept of bipolar disorder has been created in the course of efforts to market new antipsychotics and other drugs for bipolar disorder, to enable these drugs to migrate out of the arena of serious mental disorder and into the more profitable realm of everyday emotional problems. A new and flexible notion of the condition has been created that bears little resemblance to the classical condition, and that can easily be applied to ordinary variations in temperament. The assertion that bipolar disorder is a brain disease arising from a biochemical imbalance helps justify this expansion by portraying drug treatment as targeted and specific, and by diverting attention from the adverse effects and mind-altering properties of the drugs themselves. Childhood behavioural problems have also been metamorphosed into "paediatric bipolar disorder," under the leadership of academic psychiatry, with the assistance of drug company financing. The expansion of bipolar disorder, like depression before it, medicalises personal and social difficulties, and profoundly affects the way people in Western nations conceive of what it means to be human.

Who has used internal company documents for biomedical and public health research and where did they find them?

OBJECTIVE

To describe the sources of internal company documents used in public health and healthcare research.

METHODS

We searched PubMed and Embase for articles using internal company documents to address a research question about a health-related topic. Our primary interest was where authors obtained internal company documents for their research. We also extracted information on type of company, type of research question, type of internal documents, and funding source.

RESULTS

Our searches identified 9,305 citations of which 357 were eligible. Scanning of reference lists and consultation with colleagues identified 4 additional articles, resulting in 361 included articles. Most articles examined internal tobacco company documents (325/361; 90%). Articles using documents from pharmaceutical companies (20/361; 6%) were the next most common. Tobacco articles used documents from repositories; pharmaceutical documents were from a range of sources. Most included articles relied upon internal company documents obtained through litigation (350/361; 97%). The research questions posed were primarily about company strategies to promote or position the company and its products (326/361; 90%). Most articles (346/361; 96%) used information from miscellaneous documents such as memos or letters, or from unspecified types of documents. When explicit information about study funding was provided (290/361 articles), the most common source was the US-based National Cancer Institute. We developed an alternative and more sensitive search targeted at identifying additional research articles using internal pharmaceutical company documents, but the search retrieved an impractical number of citations for review.

CONCLUSIONS

Internal company documents provide an excellent source of information on health topics (e.g., corporate behavior, study data) exemplified by articles based on tobacco industry documents. Pharmaceutical and other industry documents appear to have been less used for research, indicating a need for funding for this type of research and well-indexed and curated repositories to provide researchers with ready access to the documents.

Models for financing the regulation of pharmaceutical promotion

Pharmaceutical companies spend huge sums promoting their products whereas regulation of promotional activities is typically underfinanced. Any option for financing the monitoring and regulation of promotion should adhere to three basic principles: stability, predictability and lack of (perverse) ties between the level of financing and performance. This paper explores the strengths and weaknesses of six different models. All these six models considered here have positive and negative features and none may necessarily be ideal in any particular country. Different countries may choose to utilize a combination of two or more of these models in order to raise sufficient revenue. Financing of regulation of drug promotion should more than pay for itself through the prevention of unnecessary drug costs and the avoidance of adverse health effects due to inappropriate prescribing. However, it involves an initial outlay of money that is currently not being spent and many national governments, in both rich and poor countries, are unwilling to incur extra costs.

Diagnostic inflation: causes and a suggested cure

There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.

[Bringing evidence to practice: obstacles and barriers]

Translating clinical research findings into daily medical practice is a complex procedure and subject to multiple impacts. Studies sponsored by drug manufacturers produce positive results more frequently than would be expected by chance alone; positive studies have a better chance to be published than negative ones. There is a lack of effective implementation strategies for medical guidelines. The mismatch of study population and own patients renders the generalizability of study results difficult. Other confounding factors in head-to-head studies are drug comparisons that do not conform to the gold standard, non-equivalent dosages and study duration. To solve these problems clinical research must pick up questions and problems from daily medical care. Studies independent of drug companies should be funded with public money, and health care research needs public support. Access to study protocols and data must be open to the public.

Strategies and practices in off-label marketing of pharmaceuticals: a retrospective analysis of whistleblower complaints

BACKGROUND

Despite regulatory restrictions, off-label marketing of pharmaceutical products has been common in the US. However, the scope of off-label marketing remains poorly characterized. We developed a typology for the strategies and practices that constitute off-label marketing.

METHODS AND FINDINGS

We obtained unsealed whistleblower complaints against pharmaceutical companies filed in US federal fraud cases that contained allegations of off-label marketing (January 1996-October 2010) and conducted structured reviews of them. We coded and analyzed the strategic goals of each off-label marketing scheme and the practices used to achieve those goals, as reported by the whistleblowers. We identified 41 complaints arising from 18 unique cases for our analytic sample (leading to US$7.9 billion in recoveries). The off-label marketing schemes described in the complaints had three non-mutually exclusive goals: expansions to unapproved diseases (35/41, 85%), unapproved disease subtypes (22/41, 54%), and unapproved drug doses (14/41, 34%). Manufacturers were alleged to have pursued these goals using four non-mutually exclusive types of marketing practices: prescriber-related (41/41, 100%), business-related (37/41, 90%), payer-related (23/41, 56%), and consumer-related (18/41, 44%). Prescriber-related practices, the centerpiece of company strategies, included self-serving presentations of the literature (31/41, 76%), free samples (8/41, 20%), direct financial incentives to physicians (35/41, 85%), and teaching (22/41, 54%) and research activities (8/41, 20%).

CONCLUSIONS

Off-label marketing practices appear to extend to many areas of the health care system. Unfortunately, the most common alleged off-label marketing practices also appear to be the most difficult to control through external regulatory approaches.

The inverse benefit law: how drug marketing undermines patient safety and public health

Recent highly publicized withdrawals of drugs from the market because of safety concerns raise the question of whether these events are random failures or part of a recurring pattern. The inverse benefit law, inspired by Hart's inverse care law, states that the ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed. The law is manifested through 6 basic marketing strategies: reducing thresholds for diagnosing disease, relying on surrogate endpoints, exaggerating safety claims, exaggerating efficacy claims, creating new diseases, and encouraging unapproved uses. The inverse benefit law highlights the need for comparative effectiveness research and other reforms to improve evidence-based prescribing.

Perspective: the revolution is upon us

Profound socioeconomic pressures on medical student education have been catalogued extensively. These pressures include teaching patient shortages, teacher shortages, conflicting systems, and financial problems. Many of these problems have been caused by an unregulated free market affecting medicine overall, with market values sometimes overshadowing the academic values of education, research, and patient care. This has caused profound changes in the conduct of medical student education. Particularly important has been a reduction in the "gold standard" of teaching: direct student-teacher and supervised student-patient interaction, replaced by a potpourri of online and simulated modules. The aggregate of these changes constitutes a revolution that challenges whether medical schools, school buildings, classes, and dedicated faculty are even necessary. The author posits several recommendations in response to this revolution: (1) recognize the revolution as such, and carefully guide or abort it, lest its outcome be inadequate, inauthentic, or corrupt, (2) prioritize academic rather than business values, (3) ensure that funds allotted for education are used for education, (4) insist that medical schools, not industry, teach students, (5) value authentic education more than simulation, (6) adopt learner-centered teaching without misusing it, (7) maintain acceptable class attendance without requiring it, (8) provide, from the first school day, authentic, patient-centered medical education characterized by vertical integration, humanism, early patient exposure, biopsychosocial orientation, and physician role modeling, (9) ensure that third- and fourth-year students have rich patient-care responsibility, and 10) keep tenure. These actions would permit the preservation of an educational gold standard that justifies medical education's cost.

The continued social transformation of the medical profession

A pressing concern in contemporary health policy is whether the medical profession's mandate to take care of clients has been undermined by the influx of money into health care. We examine the medical profession's transformation over the past decades. First, we review how sociologists have viewed the medical profession over the past half-century as one stakeholder among other stakeholders vying for market share and power in the health care field. We then examine three recent challenges to the profession that exemplify the tension between self-interest and collective altruism to act in the best interest of patients: (1) the rise of patient consumerism, (2) the advent of evidence-based medicine, and (3) the increasing power of the pharmaceutical industry. We show the resilience of the medical profession as it adapts and transforms in response to these challenges. We conclude with implications to help inform policy makers' assessments of how the medical profession will react to policy initiatives.