Page last updated at 09:13 GMT, Friday, 4 September 2009 10:13 UK

Prescribing the prescribed drugs?

By Patrick Jackson
BBC World Service

Pills (generic image)

About one in every hundred people faces being diagnosed with schizophrenia at some stage in their life.

Probably the last thing they and their families want to be told is that there are questions over the quality of the treatment on offer.

But there is concern in the US that drug companies have been influencing psychiatrists over what anti-psychotic drugs to prescribe.

Dr Herbert Meltzer, who pioneered the use of clozapine in America, passionately denies such interference is the norm.

He was challenged by US medical journalist Robert Whitaker over the need for medication at all when the two debated on the BBC's World Today programme.


Whitaker pointed to academic studies in Vermont and Illinois as evidence that too many schizophrenia patients are kept on medication for too long.

Herbert Meltzer
I am responsible for the atypical anti-psychotic drugs and I never made a penny in terms of the profit
Dr Herbert Meltzer
US anti-psychotic drug pioneer

In the Vermont case, patients discharged in the 1950s and 1960s were studied 30 years on.

Dr Courtenay Harding determined that one-third had completely recovered and all of those ex-patients had stopped taking anti-psychotic drugs.

"You need a paradigm of care which recognises that some percentage of patients would do better off medication and that should be built into the system," Whitaker concluded.

Suggesting the journalist was "cherry-picking" academic studies, Meltzer warned against making generalisations based on the Harding study "because there was no evidence that these people needed medication to begin with".

Acknowledging that psychotic symptoms might diminish in time because of biological changes in the brain, he pointed out that schizophrenia was "not just a disease of delusions and hallucinations [but] a disease of cognition".

Without medication, Meltzer said, there was no possibility of recovery from this cognitive impairment.

'Losing faith'

Controversy over alleged conflicts of interest has been dogging the world of US psychiatry:

Robert Whitaker
I do think there is an incredible crisis for psychiatry right now in American society because we do not believe what we are told
Robert Whitaker
US medical journalist

• In July of last year, Senator Charles Grassley demanded clarity over the finances of the American Psychiatric Association (APA)

• The US Department of Health and Human Services is investigating payments to the former head of Emory University's psychiatry department, Charles Nemeroff

• Harvard University is conducting an internal investigation into psychiatry professor Joseph Biederman, who is accused of failing to disclose payments from drug companies in full

Robert Whitaker suggests the American public is "losing faith in psychiatry as an honest profession".

"What has happened over the past 30 years is that the academic psychiatrists now receive money from the drug companies through a lot of channels: they are members of speaker bureaus, they act as consultants, they are on advisory boards," said the author of Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.

"I do think there is an incredible crisis for psychiatry right now in American society because we do not believe what we are told."

Herbert Meltzer accepted that some pharmaceutical companies had encouraged over-treatment in the past, and that there had been instances of "bad apples" in the industry.

Prescribed for the approximately one in five people with schizophrenia who do not respond to other medications
Developed by Sandoz in the 1960s but withdrawn in Europe in 1975 when it was linked to agranulocytosis
Approved in US in 1989 when its benefits were judged to outweigh the side effects
Another side effect has been identified as metabolic syndrome

But if exaggerated claims had been made for some anti-psychotic drugs, they had not been made by pharmaceutical industry publications, he insisted.

"I am responsible for the atypical anti-psychotic drugs and I never made a penny in terms of the profit from bringing forward the models that led to the profusion of drugs in that era," he added.

Meltzer contended that there would be no effective psychotropic treatments for serious mental illness today without the joint efforts of pharmaceutical companies and academics.

"There is no single drug - whether for schizophrenia, bipolar disorder, major depression or anxiety - that has ever been produced by a governmental agency," he said.

Free lunches over

While concurring that pharmaceutical firms had an important part to play in bringing new treatments to market, Whitaker called for researchers to keep a greater distance.

Impacts on thinking, feeling and behaviour
Usually starts between the ages of 15 to 35
Affects about one in every 100 people during their lifetime

"What we need is a group of independent physicians who will have a critical perspective as they figure out how to best use those drugs," he said.

"I would agree but unfortunately there are very few people who have nothing to do with drug companies but who are still as knowledgeable as the rest of us," Meltzer replied.

"But when you look at the aggregate of what we do, it is incorrect to characterise it as self-serving and abusing the public trust."

In a sign of the sensitivity that now attaches to the US pharmaceutical industry, the APA recently put an end to medical education seminars and meals sponsored by drug companies at its annual meetings.

"There is a perception that accepting meals provided by pharmaceutical companies may have a subtle influence on doctors' prescribing habits," Dr James Scully, the APA's medical director and chief executive officer, said in a statement.

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