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It seems there will be no more Zyprexa pen-knives, Prozac mugs, or Zoloft soap dispensers. Drug companies have agreed to a moratorium on free branded goodies for doctors.
I have the sense of having lived through a full cycle of a public health political movement. When I started medical school, one of our first student meetings concerned free stethoscopes. A pharmaceutical house supplied them. Some politically aware classmates believed that to accept these gifts corrupted doctors. The solution was to gather the instruments in bulk and send them to a less well-stocked Latin American country - my memory is Nicaragua, but I'm hardly confident of the destination.
I should add that the stethoscope that passed in and out of my hands was the last substantial drug company gift I received. For much of my career, the temptations on the freebie front were few. Psychiatrists would arrive at a medical meeting hall and notice that the workforce servicing the prior group - cardiologists, gastroenterologists, dermatologists, you name it - was carting out truckloads of displays from drug companies. If you think about it, in the decades preceding the advent of Prozac, there were exceedingly few new psychiatric medications (Xanax would be the notable exception), not least because it was unclear that psychiatric patients constituted a substantial market.
After Prozac and Clozaril, the deluge: we've had handfuls of me-too drugs and fierce competition for psychiatrists' attention. The meeting halls have become garish souks, places to avoid for anyone with a shred of self-regard. The retreat of the pharmaceutical houses, when it comes, will be a relief. If we end up having smaller meetings with fewer presentations - I doubt that the quality of what doctors learn will suffer.
But I wonder how much prescribing practices will improve in the new, less grubby era. Back when - before the be-logoed paperweights and flash drives - medication choice was reasonably arbitrary. For instance, you could always tell a Yale man or woman; psychiatrists trained at Yale favored Trilafon, as the antipsychotic medication that gave the best balance of main and side effects, although Mellaril might be used when insomnia was also at issue. (And still we saw a fair amount of tardive dyskinesia.) Desipramine was the tricyclic antidepressant of choice among the sophisticates, unless obsessionality was in the picture, in which case the nod went to imipramine. None of this practice would have met the standards of a Cochrane report, although, to be fair, clinicians' experience did inform the choices. A certain amount of arbitrariness will be built into any system where the problems at hand bear only a tangential relationship to the choices for which objective data are available. And of course the great shortcoming of the past era was the frank undertreatment of depression, by whatever modality, talk or pills.
Good riddance to the mugs and pens. And welcome, welcome to every move toward transparency regarding drug trials and doctors' affiliations. Less cash flowing around would be a fine thing altogether. Surely random arbitrariness is better than preferences guided by commercial advertising.
But are we entering a golden age? My impression is that psychiatrists' reputations are simply on the wane, that no change in rules or behavior will change that fact for some time, and that the result will be later and less expert treatment of common disorders. I also foresee less focus on drug development in the mental health sector, which of late has been only a headache for Big Pharma. Whether those results are good or bad depends on your viewpoint. I don't find the prospect a wholly happy one. I liked the more evident cleanness of psychiatry in my early years, but - aside from the enthusiasm for a wide range of psychotherapies, a state of affairs I'd love to see return - I'm not convinced that patient care was better.
