We don’t usually watch TV at our house, so are a bit out of touch with TV advertising. However, with the Olympics, we dug up an antenna and suddenly the TV is back on. And what we’ve been watching is pretty amazing.
It’s not just that there seems to be more time spent on advertisements than on the Olympics itself. It’s the number of medically related advertisements as well as the misleading information they contain that made my jaw drop.
“High technology is best,” and “the more technology the better,” are clear messages in the advertisements for hospitals and medical devices. Hospitals are luring patients with the promise that they have the newest facilities and the most technology. The reality is, though, that when patients do need hospitalization, it is the amount of experience that the physicians have with the technology that makes the difference. New technology in inexperienced hands is a recipe for waste and bad outcomes. None of the hospital advertisements mentioned the actual complication rates for their facilities nor the number of doctors, if any, who had significant enough experience with the promised technology to actually be competent using it. There is no data out there that proves that a new building leads to better patient outcomes. Sure, patients like a nice, clean, facility. But don’t let the new gloss make you think that you will get higher quality care. You will, however, be getting higher cost care. The new hospitals imply that those pesky poor and uninsured patients won’t be showing up at their new facilities located in the wealthiest suburbs. They don’t mention that even if you have insurance, their higher charges will be reflected in your higher premiums. They make a profit. Your insurance company makes a profit. In the long term, though, everyone suffers.
A device manufacturer is advertising its hand held portable ultrasound machine to the public. They show a series of people who supposedly have abdominal pain; different health care providers, from ancient times to the present, come up to these patients and say, “let’s take a look.” No one actually examines the patients or even seems to talk with them. They go immediately to the “lets take a look” behavior. Finally, the current, modern doctor pulls up the patient’s shirt and does an ultrasound.
The message that technology brings us out of the dark ages and is far superior to “just taking a look” is very clear. What is not apparent, though, is the fact that the vast majority of diagnoses (up to 85%, as I was taught in medical school) are made on the basis of the medical history alone. In other words, if you want to know what is wrong with your patient, you talk to them. You ask them about their symptoms, when they started, what makes them better and worse, whether they are constant or come and go, that kind of thing. With a thorough history, a characteristic pattern emerges. For instance, the patient with pain in the upper right abdomen that comes on suddenly after a fatty meal, doubles them over, is so painful they can’t find a comfortable position, gets more and less severe in waves, lasts a couple of hours and goes away, is associated with dark urine and light colored stools, and may have shoulder pain associated with it, is most certainly gall bladder disease. A totally different pattern of symptoms characterizes a stomach ulcer or appendicitis or ulcerative colitis. When the history is classic, the diagnosis is certain.
Another 7% of diagnoses are made on the basis of the physical exam. In case the history may have been a bit ambiguous, the physical exam may not be. The patient with pain in the upper middle abdomen who jumps when you press on their lower right abdomen probably has early appendicitis. The patient with middle abdomen symptoms who has exquisite pain when you press under the right ribs probably has gallbladder disease.
After the history and the physical, laboratory and radiology tests simply confirm what the physician already knows. Once you’ve made the diagnosis of gallstones, it is just a matter of form to find them on an ultrasound. Funny thing, though. A normal test does not mean you don’t have the disorder suspected. An ultrasound isn’t going to show appendicitis. It may be normal if you’ve already passed the gallstone or kidney stone. It is rare, indeed, that a test shows something that you had no idea would be there. How convenient that the advertisers don’t bother to mention just how limited the usefulness of their tests really are. How frustrating for us that we are led to believe that we should pay several hundred dollars to have an ultrasound when our diagnosis can be made without it.
And then there are the pharmaceutical advertisements. These are illegal in most countries, and until a few years ago were illegal here. Just like the hospital and device advertisements, they are also misleading. They imply that your life will be better if you use their medication. For instance, a new lipid lowering agent implies that you need to take it to live longer and avoid heart disease. They do not mention that you actually will have results just as good if you take the generic version of medications already out there. And that you won’t have any adverse side effects if you lose weight and exercise. And that their medication costs 10 or 20 times what a generic costs.
There are ads for antipsychotic agents that imply that you need to take them with your antidepressant if you are depressed. They fail to mention that the best treatment for depression is therapy coupled with traditional antidepressants, and that there is no antidepressant out there superior in effectiveness to any other antidepressant. Further, there is no evidence that in those few patients who do not do well on an antidepressant alone that the antipsychotic they are advertising, which costs in the range of $800 a month, would be any more effective than any other available augmentation strategy, like a second antidepressant from a different class or low dose thyroid, both of which can cost under $10 a month and do not have the serious side effects that antipsychotics can have.
It would be wonderful if all medical advertising is eliminated. It leads patients to demand newer technology, meds, and facilities, which raise the cost of medical care in this country without resulting in ANY improved outcomes. Instead of medical advertising, we should have public service announcements that discuss the actual risks and benefits of treatments, the times that tests might be helpful, and presentation of evidence based recommendations for screening or treatments.
In the meantime, TV watchers sit there slack jawed, soaking in all that false information, wanting, even demanding, to have what they are told they want. In our house, though, we are taking down the antenna and turning off the TV. We will get to bed earlier, avoid brainwashing from all that advertising, and if we really need to watch the Olympics, instead of just reading about the results, we can watch it on the internet for free the next day. After all, the results don’t depend on whether or not we are on the other side of the TV watching. And they will be just as exciting, and probably more so, when not interrupted by the interminable ads. Now if I can just figure out how to avoid those pesky internet advertisements, too.
Monday, February 22, 2010
Wednesday, February 3, 2010
The marketing of Seroquel
The marketing of Seroquel
Seroquel is one of several medications called atypical antipsychotics that have changed psychiatric practice over the last decade. While older, “typical” antipsychotics, like thorazine, mellaril, and haldol, were very effective in the treatment of psychosis and schizophrenia, their use was limited by their serious side effects, especially movement disorders, which sometimes progressed to permanent disability. When the atypical antipsychotics were invented, they were heralded as safer medications without the risk of movement disorders, drug interactions, mental status changes, and other problems.
While there reportedly are 2.4 million patients in the US who have a diagnosis of schizophrenia, in most outpatient, private psychiatry practices, psychosis makes up only a small minority of patient problems, dwarfed in scale by depression, anxiety, and bipolar disorder, among other problems. Yet, over the last decade, the atypical antipsychotics, with Seroquel leading the pack, have come to dominate psychiatric prescribing in both the public and private sectors. According to Reuters, Seroquel generated $4 million in sales world wide, and is the leading seller of all antipsychotics.
AstroZeneca, the maker of Seroquel, has conducted a masterful marketing campaign for its product. Not only does it represent Seroquel as safer than typical antipsychotics, in marketing to physicians, Seroquel is promoted as not only being effective for psychosis, but also for bipolar disorder and as an adjust for depression. Some family doctors even use it as a sleeping pill and for anxiety.
Many physicians, including psychiatrists, get much of their pharmaceutical education from drug representatives. These salesmen and women are trained to appear concerned, compassionate, and well informed about their product. However, they conveniently neglect to mention, and the physicians seem unaware of, the CATIE trial, sponsored by the National Institute for Mental Health, and published in 2005. This large trial compared the newer antipsychotic medications with the older class of antipsychotic drugs, and showed that :
Contrary to expectations, movement side effects (rigidity, stiff movements, tremor, and muscle restlessness) primarily associated with the older medications, were not seen more frequently with perphenazine (Trilafon) (the drug used to represent the class of older medications) than with the newer drugs. The older medication was as well tolerated as the newer drugs (Including Seroquel) and was equally effective as three of the newer medications (including Seroquel). … Thus, taken as a whole, the newer medications have no substantial advantage over the older medication used in this study. NIMH
Also according to the NIMH, “about 80 percent of the prescriptions for antipsychotics are paid via the public sector. The new atypical medications, representing 90 percent of the current market, are approximately 10 times the cost of the older conventional antipsychotics.”
For regular folks who pay for medications out of pocket, perphenazine, which comes in generic, costs about $20 month, regardless of the strength. Older antipsychotics like thoridizine and haloperidol can be purchased at chain stores like Walmart or Target for $4 a month. Lithium, for bipolar disorder costs $4. Citalopram for depression costs $4. Seroquel costs $400 to $800 a month or more. For the non- public sector patient, that represents a 100 fold increase in the cost of their medications.
Seroquel is not a benign medication. There have been over 14,000 reports of Seroquel being associated with weight gain, diabetes, oversedation, movement disorders, and a myriad of other problems. AstroZeneca paid over $500 million to settle claims in 2009. And still, despite all the side effects, lack of superiority over traditional antipsychotics, lack of superiority over mood stabilizer for bipolar disorder, and lack of indications for sleep or anxiety, Seroquel continues to dominate the field among all antipsychotics. Because the company will lose its patent over Seroquel in 2012, it has already developed and patented a long acting form of the drug, which acts in the same way with the same side effects and is no more effective than Seroquel. They are aggressively marketing that form of the medication with the expectation that their new medication will have captured the market by the time Seroquel goes generic.
What I see now among the psychiatrists that work with patients in my statewide, managed practice, is that patients are frequently, if not usually, put on Seroquel or other atypical antipsychotics, and continued indefinitely, even in the face of unclear diagnoses. And these patients suffer the consequences. They get salivary gland infections and dry mouth, painful sustained erections, constipation, abdominal pain, acid reflux, weight gain, new diabetes, poor control of pre existing diabetes, medication interactions, and a host of other major and minor side effects. Even more frustrating is that when the prescribing psychiatrist is asked by the medical provider to reassess the use of Seroquel, invariably the psychiatrist simply switches the patient to a different, equally expensive, equally problematic antipsychotic. I suspect that the majority of these patients never needed an antipsychotic in the first place. Antipsychotics have become convenient medications for the management of problem patient behaviors even when the patients don’t have clear psychiatric diagnoses.
Certainly as patients, we all need to pay attention to unnecessary prescribing by our physicians, by asking for evidence-based information, by asking for generic medications, and for a treatment plan that is patient and diagnosis specific. This means that you not only know what you are being treated with and why, but how long the treatment is for and what you need to do in order to be able to get off the medication in the future.
And as citizens, we need to care about the enormous waste of money being generated by the undue influence of pharmaceutical companies. In order that our money is not continuing to be wasted on unnecessarily expensive medication that do not improve outcomes:
1. Drug companies should not be allowed to advertise prescription medications to the public. That practice is illegal everywhere else in the world and should be illegal here.
2. Drug company marketing to physicians should also be halted. They should not be allowed to sample medications to physicians, provide lunches or other sales pitches, and really should have no direct contact with the medical profession at all.
3. Access for physicians to accurate and evidence based information about drugs should be more accessible. Perhaps the AMA should get involved in informing physicians about reliable sources of information; perhaps licensing boards can require that physicians obtain unbiased pharmaceutical education for relicensing.
4. There needs to be oversight and regulation of medication use in public programs, including medicare, medicaid, community mental health, and others.
5. Physicians should be rewarded for practicing cost effective and evidence based medicine.
6. A national health program should include pricing limitations for pharmaceutical companies, federally supported and unbiased drug comparison research, and evaluation and monitoring of physician and hospital prescribing practices.
Seroquel is one of several medications called atypical antipsychotics that have changed psychiatric practice over the last decade. While older, “typical” antipsychotics, like thorazine, mellaril, and haldol, were very effective in the treatment of psychosis and schizophrenia, their use was limited by their serious side effects, especially movement disorders, which sometimes progressed to permanent disability. When the atypical antipsychotics were invented, they were heralded as safer medications without the risk of movement disorders, drug interactions, mental status changes, and other problems.
While there reportedly are 2.4 million patients in the US who have a diagnosis of schizophrenia, in most outpatient, private psychiatry practices, psychosis makes up only a small minority of patient problems, dwarfed in scale by depression, anxiety, and bipolar disorder, among other problems. Yet, over the last decade, the atypical antipsychotics, with Seroquel leading the pack, have come to dominate psychiatric prescribing in both the public and private sectors. According to Reuters, Seroquel generated $4 million in sales world wide, and is the leading seller of all antipsychotics.
AstroZeneca, the maker of Seroquel, has conducted a masterful marketing campaign for its product. Not only does it represent Seroquel as safer than typical antipsychotics, in marketing to physicians, Seroquel is promoted as not only being effective for psychosis, but also for bipolar disorder and as an adjust for depression. Some family doctors even use it as a sleeping pill and for anxiety.
Many physicians, including psychiatrists, get much of their pharmaceutical education from drug representatives. These salesmen and women are trained to appear concerned, compassionate, and well informed about their product. However, they conveniently neglect to mention, and the physicians seem unaware of, the CATIE trial, sponsored by the National Institute for Mental Health, and published in 2005. This large trial compared the newer antipsychotic medications with the older class of antipsychotic drugs, and showed that :
Contrary to expectations, movement side effects (rigidity, stiff movements, tremor, and muscle restlessness) primarily associated with the older medications, were not seen more frequently with perphenazine (Trilafon) (the drug used to represent the class of older medications) than with the newer drugs. The older medication was as well tolerated as the newer drugs (Including Seroquel) and was equally effective as three of the newer medications (including Seroquel). … Thus, taken as a whole, the newer medications have no substantial advantage over the older medication used in this study. NIMH
Also according to the NIMH, “about 80 percent of the prescriptions for antipsychotics are paid via the public sector. The new atypical medications, representing 90 percent of the current market, are approximately 10 times the cost of the older conventional antipsychotics.”
For regular folks who pay for medications out of pocket, perphenazine, which comes in generic, costs about $20 month, regardless of the strength. Older antipsychotics like thoridizine and haloperidol can be purchased at chain stores like Walmart or Target for $4 a month. Lithium, for bipolar disorder costs $4. Citalopram for depression costs $4. Seroquel costs $400 to $800 a month or more. For the non- public sector patient, that represents a 100 fold increase in the cost of their medications.
Seroquel is not a benign medication. There have been over 14,000 reports of Seroquel being associated with weight gain, diabetes, oversedation, movement disorders, and a myriad of other problems. AstroZeneca paid over $500 million to settle claims in 2009. And still, despite all the side effects, lack of superiority over traditional antipsychotics, lack of superiority over mood stabilizer for bipolar disorder, and lack of indications for sleep or anxiety, Seroquel continues to dominate the field among all antipsychotics. Because the company will lose its patent over Seroquel in 2012, it has already developed and patented a long acting form of the drug, which acts in the same way with the same side effects and is no more effective than Seroquel. They are aggressively marketing that form of the medication with the expectation that their new medication will have captured the market by the time Seroquel goes generic.
What I see now among the psychiatrists that work with patients in my statewide, managed practice, is that patients are frequently, if not usually, put on Seroquel or other atypical antipsychotics, and continued indefinitely, even in the face of unclear diagnoses. And these patients suffer the consequences. They get salivary gland infections and dry mouth, painful sustained erections, constipation, abdominal pain, acid reflux, weight gain, new diabetes, poor control of pre existing diabetes, medication interactions, and a host of other major and minor side effects. Even more frustrating is that when the prescribing psychiatrist is asked by the medical provider to reassess the use of Seroquel, invariably the psychiatrist simply switches the patient to a different, equally expensive, equally problematic antipsychotic. I suspect that the majority of these patients never needed an antipsychotic in the first place. Antipsychotics have become convenient medications for the management of problem patient behaviors even when the patients don’t have clear psychiatric diagnoses.
Certainly as patients, we all need to pay attention to unnecessary prescribing by our physicians, by asking for evidence-based information, by asking for generic medications, and for a treatment plan that is patient and diagnosis specific. This means that you not only know what you are being treated with and why, but how long the treatment is for and what you need to do in order to be able to get off the medication in the future.
And as citizens, we need to care about the enormous waste of money being generated by the undue influence of pharmaceutical companies. In order that our money is not continuing to be wasted on unnecessarily expensive medication that do not improve outcomes:
1. Drug companies should not be allowed to advertise prescription medications to the public. That practice is illegal everywhere else in the world and should be illegal here.
2. Drug company marketing to physicians should also be halted. They should not be allowed to sample medications to physicians, provide lunches or other sales pitches, and really should have no direct contact with the medical profession at all.
3. Access for physicians to accurate and evidence based information about drugs should be more accessible. Perhaps the AMA should get involved in informing physicians about reliable sources of information; perhaps licensing boards can require that physicians obtain unbiased pharmaceutical education for relicensing.
4. There needs to be oversight and regulation of medication use in public programs, including medicare, medicaid, community mental health, and others.
5. Physicians should be rewarded for practicing cost effective and evidence based medicine.
6. A national health program should include pricing limitations for pharmaceutical companies, federally supported and unbiased drug comparison research, and evaluation and monitoring of physician and hospital prescribing practices.
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