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In this opinion piece, Lawrence Diller explores the implications of Joseph Biederman’s undeclared $1.6 million in drug company consultation fees.

“Are Our Leading Pediatricians Drug Industry Shills?”

Date Published:

Jul 13, 2008 01:00 AM

Author: Lawrence Diller, M.D.

Source: San Francisco Chronicle

Most parents have neverheard of him, but Joseph Biederman of Harvard may be the United States’most influential doctor when it comes to determining whether theirchildren are normal or mentally ill.

In 1996, for example, Biederman suggested that drugs like Ritalinmight serve 10 percent of American kids for Attention DeficitHyperactivity Disorder. By 2004, one in nine 11-year-old boys wastaking the drug. Biederman and his team also are more responsible thananyone for a child bipolar epidemic sweeping America (and no othercountry) that has 2-year-olds on three or four psychiatric drugs.

The science of children’s psychiatric medications is so primitiveand Biederman’s influence so great that when he merely mentions a drugduring a presentation, tens of thousands of children within a year ortwo will end up taking that drug, or combination of drugs. This happensin the absence of a drug trial of any kind – instead, the decision isbased upon word of mouth among the 7,000 child psychiatrists in America.

That’s why Iowa Sen. Charles Grassley’s recent revelation thatBiederman did not declare $1.6 million in drug company consulting feesis so important, scary and tragic. If true, this scandal is yet onemore stake in the heart of American academic medicine’s credibilitywith frontline doctors like me – and more importantly, with the parentsof the patients I deal with every day.

American medicine, with psychiatry the most culpable, has fallenback to a time more than 100 years ago when doctor credibility wastantamount to the promotion of patent medicine. Subsequent reformssevered ties between medical school doctors and the drug industry – andfor decades there was a much more ethical balance between the industryand physicians.

Now once again, drug company money is corrupting medical practiceand the maintenance of our country’s health. In a market economy, bothdoctors and the companies are motivated by profit. However, doctors’Hippocratic oath and their personal/professional relationships withtheir patients attenuate the most crass aspects of a fee-for-servicesystem.

In contrast, drug companies owe primary responsibility to theirshareholders. Of course these companies must operate within legalbusiness and Food and Drug Administration restraints, but the drive topush such rules to the limit is implicit in any business.

Such a strategy isn’t always beneficial when our children’s health is affected.

The Fortune 500 drug companies, by their sheer economic clout, havebecome the single most dominant influence in our health care system.The ambiguities of children’s mental health and illness make childpsychiatry the most vulnerable branch of medicine open to suchinfluence.

In this climate, drug company research money, professional medicaleducation and direct advertisements to parents tilt families anddoctors to biologically brain-based solutions, rather than nondrug(e.g., parenting and education) approaches.

That’s why we’re seeing famous (or infamous) Newsweek cover boyslike Max, a 10-year-old who has taken 38 psychiatric medications in hisshort, unhappy life.

Research funding must be directed to the needs of patients and theirdoctors – not to the bottom line of stockholders. Drug companies canstill make money, but it’s ethically immoral when stockholder profitstrump children’s health needs (as in the cover-up of negative studiesof antidepressants in children).

More money must be directed toward head-to-head competition betweenexisting generics and the new products, and toward more studiescomparing nondrug or combination approaches to drug-only interventionsfor children’s problems.

Drug company funding of medical research is not going to end – norshould it entirely stop. Yet a new set of federal rules dictating thetransparency and direction of such funding is desperately needed toredress a dangerously corrupt system. It’s not enough to simply havedoctors more explicitly report their incomes from drug companies,though it is a very useful first step.

I remember about six years ago when I read a major article by theBiederman team on the advantages of a non-Ritalin drug pathway forADHD. On the same day, much to my dismay, I also heard him give aspeech – for a Wall Street audience – promoting a new drug by Eli Lillycalled Strattera.

Although Strattera turned out to be a bust both clinically andcommercially for ADHD, I was still shaken that such a prominentresearcher could be so brazen with his potential conflict of interestappearance.

The $1.6 million that Biederman didn’t declare is only a smallfraction of the full amount of research funding that his clinicreceives from nearly a dozen companies that pay for not only the costof running studies but also the salaries of the doctors involved.Virtually all doctors who receive drug company money say they are notinfluenced, but every independent study examining the effects of suchmoney says they are.

The leadership of Harvard’s psychiatry department is strangelysilent or even defends Biederman. These are good men with solidreputations both in drug and nondrug aspects of treatment. Yet theyknow that their psychiatry department would not exist were it not fordrug company money – considering the withdrawal of federal researchdollars over the past 25 years and the meager reimbursements thatpsychiatrists receive for their services from insurance companies andMedi-Cal.

Sens. Grassley, a Republican, and Herbert Kohl, a WisconsinDemocrat, have introduced the Physician Payments Sunshine Act, whichwill require more vigorous reporting and enforcement on payments(anything more than $500) received by doctors from drug companies.

But in addition, we need laws to have the federal government, alongwith the major academic research centers, coordinate and direct the useof drug company money in medical research. This is not pie-in-the skywishing. Such reform was precisely what the doctors of 100 years agoaccomplished in this country.

Lawrence Diller, M.D., practices behavioral-developmentalpediatrics in Walnut Creek and is on the clinical faculty of UCSF. Heis the author of “The Last Normal Child” (Praeger, 2006). Contact us