Well, maybe not really, but you might think so if you read about this recent study and accompanying editorial in the Journal of the American College of Cardiology that is hot off the press (thanks to Marilyn Mann who is an ACC member for getting the paper for guys like us to review, when the paper isn’t even out yet even though they are blowing the press releases all over the mainstream media).

New New! Lolcat! I done wanna die!

This study looked at 63,469 women in the Nurses Health Study who didn’t have a history of heart disease, divided them into different levels of depression based on the self report Mental Health Inventory, and then followed them over several years. They found the usual associations between depression and risk of heart attack, but what was more interesting was the fact that women on antidepressants were three times as likely to have a sudden cardiac death than women not on antidepressants. This was pretty striking, and was not accounted for by other factors such as risk factors for heart disease. Granted, sudden cardiac death in healthy women is fairly rare, and in this study only 46/100,000 women on an SSRI had a sudden cardiac death.

Tricyclics have long been known to prolong the cardiac Q-T interval, so they could theoretically cause ventricular arrhythmia, leading to sudden death. The SSRIs have been promoted as being safer from this standpoint, however in the current study there were not any differences between SSRIs and “other antidepressants” in terms of sudden cardiac death.

The graph below shows the risk of sudden cardiac death over time. It is called a “survival curve” and shows what percentage of the women had died up to that point of time. The women who were most depressed and on antidepressants are the blue line; they were most likely to die. Behind them are nondepressed women on antidepressants, and women not on antidepressants.

We are climbing... Jacob's ladder...

Mrs. Bremner’s comment is that sudden cardiac events is fairly rare in otherwise healthy women, and antidepressants did not increase the risk of other cardiac events that are more common, like heart attack and stroke. Nevertheless she thinks it is worth paying attention to.

More reactions to this study here and here.

Senator Charles Grassley, up to his usual mischief, has released a brochure from a GlaxoSmithKline program called “Psychnet”, which was developed in 2000 in order to promote sales of their antidepressant Paxil (paroxetine). Psychnet involved getting a bunch of influential psychiatrists together and training them to go out and give talks to other psychiatrists. Here are the program objectives:

• Develop and/or solidify relationships with key influential psychiatrists and primary care physicians
• Develop these physicians into knowledgeable and engaging speakers on Paxil and its effective treatment on mood and anxiety disorders
• Build advocacy amongst PsychNet physicians by creating speaking opportunities

This is an internal document and shows what industry is thinking about psychiatry “key opinion leaders” (KOLS). Those are the influential physician guys. I think the choice of language is illuminating: “build advocacy” by “creating speaking opportunities”? In other words, set up high paying speaking gigs for the big boys, not cuz you are good guys who want to educate, but to provide a way to transmit money (and therefore good will and influence) with those leaders who will in turn influence the little guys to prescribe your drug.

That is actually a violation of federal anti kickback laws as far as I can tell. The Justice Department is actually using this law now to prosecute Forest labs for illegal promotion of off label use of the antidepressants Celexa and Lexapro for teenagers (for whom they do not work, and can be harmful). Here are some quotes from todays NY Times:

“Somehow physicians think they’re different from the rest of us,” Mr. Morris said. “But money works on them just like everybody else.”

Mr. Sullivan, the United States attorney, said officials hoped to send a strong message to doctors. “I have been shocked at what appears to be willful blindness by folks in the physician community to the criminal conduct that corrupts the patient-physician relationship,” he said.

Anyway the PsychNet Program goes on to state that:

PsychNet is an ideal way for key opinion leaders to influence clinicians in your region on the benefits of Paxil versus competitors.

PsychNet Speakers – Selection and training

Each region selected several physicians who are influential in their communities, credible and interested in speaking on behalf of Paxil. Specifically, the phyisicians met the following criteria:

• Local key opinion leaders
• Educated on the benefits of Paxil
• Strong communication skills

A list of regional speakers can be found at the back of this booklet.

I am not making this up, guys. The program goes on to say that only doctors that had gone through the program could give talks, because they were “educated” on the advantages of Paxil over competing drugs for depression and anxiety.

Those guys know that physicians look up to their KOLs, first during training, then later to get updates on what is new. That is why it is so concerning when they get co-opted by drug companies, which is what has happened in the US today.

I wanna be like u when I grow up!

That’s our dog Lydia, who tragically met her demise five years ago.

I actually gave a talk for a program like this somewhere around 2001 in Orlando, FL. Right before I went out to give my talk one of the industry guys said:

Go out there and sell some Paxil, Doug!

That was when I started to realize that something was terribly wrong.

My kids got to go to DisneyWorld, though. First and last time.

Bremner kids have fun while Dad sells drugs.

That’s a real picture. No kidding.

Anyhoo after the DisneyWorld show I had a gig for a year speaking in a program called “What Does Neurobiology Tell Us?” Well what it told us obviously was that we should be prescribing antidepressants, of course! I used to try and change the slide cuz I thought it was doing a paid infomercial to use only their slides but present myself as coming from Emory University (and not the drug company). They said they couldn’t do that cuz the slides were “FDA approved” (?). Go figure. So I would show up and switch the slides at the last minute. At the end of the year they dropped me.

In retrospect it would have been a lot easier to just go along with the program and not fight them.

Relax and have some wine with your drugs! And some cash!

But then I wouldn’t get to play with lolcats!

WE HAZ GOOD TIMZ HEAR AT DRUG NEWZ BLOG!

The next generation of young doctors seems to be putting up a fight against pharma corruption. But we all know about the ideals of youth.

Nevertheless, consider this an open invitation to the American Medical Students Association in the fight to withstand influence; I am willing to help in any way I can. Just let me know.

[update: more responses to the PsychNet brochure here. Also, as some readers point out in the comment section, why are some regions (SE, Midwest) not included in the brochure? Any bias?]