ne of our psychiatry residents smiles and leans
against the wall. A woman, a few years younger, stops filling the
mailboxes with pens and sheets of paper advertising a new
antidepressant and faces him squarely. Her voice is melodic and
bouncing. Her eyes open wide and she laughs at something. He smiles.
He moves to scratch his cheek and she makes the same movement, they
are scratching in unison now. They remind me of a flirting couple on
a first date.
He has completed medical school and is in the second of four
years of psychiatric training. Assuming all goes as planned, in a
few years he will be licensed as a psychiatrist.
When he starts practicing independently he will write thousands
of prescriptions every year; he already writes hundreds. She is
"detailing him," teaching him new uses for her company's
My office sits just outside the mailboxes and I've been watching
her. She's been lurking, slowly filling the mailboxes. He is the
third resident she has "detailed" in an hour.
Our psychiatry department at the University of Arizona is divided
over these interactions. On one hand, a number of professors and a
few residents have grown concerned that the department is allowing
the pharmaceutical industry to teach our residents to embrace newer,
more expensive drugs. On the other, many residents have argued
against restrictions, suggesting that they should learn to respond
to the marketing now and that prohibiting contact would leave them
unprepared for the future. A minority have argued that academic
freedom gives the faculty and residents the right to speak with
whomever they choose.
There have been debates in a grand rounds forum, in faculty
meetings, and in the weekly resident lunch. In response, our
department head recently formed a committee to draft a new policy
governing relationships with the pharmaceutical industry.
Drug company representatives are a major presence. They sponsor
Journal Club (where trainees learn to review new data and research),
they pay for many of our weekly speakers and regularly offer free
dinners for the residents and faculty. They enjoy free access to our
mailboxes and regularly detail our trainees in their offices,
hallways and in our little kitchen.
This is not uncommon. Meredith Rosenthal at the Harvard School of
Public Health reported in The New England Journal of Medicine that
the industry spends roughly $15.7 billion annually marketing
medications, with $4.8 billion dedicated to detailing individual
physicians, or roughly $6,000 to $11,000 a doctor a year.
Studies indicate that most physicians meet with pharmaceutical
representatives four times a month.
Studies also reveal that most physicians erroneously believe the
representatives do not influence prescribing habits.
When doctors and trainees meet with reps, they change their
prescribing habits and are far more likely to prescribe the drugs
described, even when they are more expensive or have no benefit over
alternatives. They are also more willing to request illogical
changes to hospital guidelines that govern which drugs can be
Estimates suggest that roughly $1 billion was spent advertising
antidepressants to health professionals in 2000.
More than 400 psychiatrists were asked by Dr. Timothy Peterson
and his colleagues at Harvard to describe their beliefs about
antidepressants. More than half said they believed that newer agents
were more effective than older antidepressants known as tricyclic
antidepressants and that newer antidepressants, called selective
serotonin reuptake inhibitors, or S.S.R.I.'s, had fewer side effects
than generic S.S.R.I.'s.
But studies conducted at Oxford, Duke, the University of
Manchester and the Canadian Coordinating Office for Health
Technology that used a statistical strategy called meta-analysis to
combine the results of hundreds of independent studies found that
S.S.R.I.'s were as effective as tricyclic antidepressants or
slightly less effective. They also revealed that S.S.R.I.'s were
tolerated by slightly more patients but had as many side