How is this website funded?
(revised 6/2009; update on the revision, 6/2010)
Short answer: I used to take pharmaceutical company money for giving talks -- my talks, not theirs -- about bipolar disorder, then use some of that money to fund my time writing this website. I also used it to fund care of people who couldn't pay their co-pays, or sometimes their whole bill, and to fund time to write other education stuff and put it on the web for free. It was a good gig until the companies asked for too much selling of their products... So I quit that and went back to work for my local hospital. My annual pre-tax income has been about the same, around $120K in 1995, and about $170K in 2010, whether I was working for the hospital or in private practice.
That was the short answer? Well, as you probably know, pharmaceutical company money is all over the mental health business, so you should suspect it might be here somehow. If you want the details of how I've tried to avoid being corrupted by their $, then read the long answer below. Thanks for your interest. [Note that I have not revised the time frame in the text below; this was my disclaimer when I was taking pharmaceutical money. I am not now, not since about 3/2009.]
Long answer: Good question -- indeed, this is one of the best questions to determine if a website is really going to give you valid information.
Teaching patients and families about bipolar disorder has been criticized as "disease mongering". In other words, the entire story about "Depression Plus" on this site (about bipolar variations that don't have "mania" or look like the "bipolar" you may know) could be a big advertisement funded, indirectly, by the drug companies whose medications are used to treat the symptoms of Depression Plus. Keep that in mind. I replied to an article about this problem thus: Confessions of a Disease Monger.
However, in this case:
This website was my idea. It was written with no funding at all. After all the site was up and several updates had already been completed, I received a grant from Abbott Laboratories, and that only because I wrote them asking for one. I figured, and they agreed, that they might benefit from people reading all this. They make a costly version of a now-generic medication, divalproex. That Abbott grant was in 2001. GlaxoSmithKline (GSK) provided a small grant in 2003 which likewise was received years after the site was up and running. They make lamotrigine.
In late 2004, GSK placed me on their national speaker's list and began paying me very large amounts when I speak for them (update 2009: their product is now generic, and they have just stopped their marketing, so I'm no longer taking any money from them). See below about how this might affect information presented here. However, as evidence of my neutrality, try this. Three different companies have either: not let me on their panel after offering it (Lilly); not had me speak after the standard "training" (Abbott); or taken me off the speakers list after a while (Wyeth). I presume these steps were taken because they discovered I would speak my mind freely; or because I would not use their slide sets, which amount to advertisements, in most cases; and perhaps because sometimes I said bad things about their medications, which are repeated on this website as well.
Update 5/2007: a very revealing article on the methods of the pharmaceutical company representatives, the techniques they used to influence physicians, was just published in a journal which is probably far less influenced by the pharmaceutical industry than many other journals in psychiatry. This is required reading for anyone interested in how pharmaceutical companies sell their medications. It describes the friendships pharmaceutical company representatives form with doctors as a means of selling their drugs. I am certain that these techniques have been used on me. Indeed, I have formed friendships with several representatives in the process of taking their money, money used as described below. I still think I am maintaining my ability to think independently, and practice accordingly, but as I emphasize throughout this website, you must be cautious about this and take what I say with a grain of salt. You should definitely compare what I say with other opinions, and form your own.
Update 11/2007: read Dr. Drug Rep by Daniel Carlat, M.D. for a first-hand account of the subtle pressure on a physician speaker to endorse the medication made by the company from which he or she is taking money. I am subject to the same pressure. You would have to ask someone who has attended one of my talks to confirm this, but I still think -- after going through the exact same thought process that Dr. Carlat describes -- that I am managing to stay neutral. Oh, I still show the company slides where required, and emphasize (for example) "this is what AstraZeneca wants you to know". But as quickly as possible we move to a discussion of bipolar diagnosis; and when we come around to treatment, I moderate an open-ended discussion in which I try to emphasize treatment approaches with solid, well accepted evidence for their efficacy. I only give talks for companies who allow this approach, so I am not -- I don't think -- in Dr. Carlat's position.
Indeed, I once gave talks for Wyeth, the company he uses as an example. When they required that I use their slides, as he describes, I declined any further invitations to speak for them. But before that, I did give a talk once for Wyeth in which I found myself promoting Effexor, just as Dr. Carlat did (after the same training experience with Drs. Thase and Sussman, who had a similar influence on me). I had the same feeling he describes: "whoops, I just went over the line". I remember that particular talk vividly (Dr. Robert Burton, a local internist colleague, was there, for example). I still feel guilty about that one. I don't want to have that feeling again.
More Details for the Skeptical (good for you!)
Pharmaceutical company funding of education activities in medicine is a huge issue. It's hard to tell what's a real research finding and what's a promotion, sometimes. I'll offer you a link to a strong criticism of the drug companies at the bottom of this page. But first, in defense of my own practices, here's an explanation of how I'm using money from drug companies:
1. How much money do I get?
It's going to sound like a lot, so hear this first. I use the big bucks:
to make this site available free of charge;
for my time spent updating it (see What's New?; about 2-3 new sections or revisions a month);
to continue the "ask-a-doc" gig for BipolarWorld.net, up to six letters a week;
to answer about 3 or 4 letters a week from those which come directly to me;
to take calls from doc's (mostly local colleagues) who call asking for help with a patient in their office, which is desperately needed in my area where all of the psychiatrists having waiting lists (and where I figure I can help more patients by helping their primary care doc's treat 'em, than if I took another couple of them myself instead of being available for consultation);
to work in a local free clinic once a month where I added psychiatry to their medical services, and got several other psychiatrists to join in (they've all stopped, but over 5 years later I'm still going -- in part because the pharmaceutical companies have paid for time I can spend doing this).
subsidizing my practice for the 1/3 of my patients who in some way can't pay, described below.
See if you think I'm just fooling myself. Insurance payments for my private psychiatry practice are steadily becoming more of a problem. Most of my patients have seen their co-payments go from $10 to as much as $40 in the last year or two. Many of them now have deductibles that are $1000 or greater, with separate deductibles for mental health (which ought to be illegal, it is so discriminatory). One of my patients had only a single visit paid for by insurance in 2004. All the rest, about 7 appointments, came out of his pocket, or would have: he is on disability now and his family can't afford that kind of expense. More and more of my patients can't really afford to pay me.
But, thanks to the huge honoraria from the drug companies, I can afford to see them for nothing, or in some cases, for what they feel they can afford. This is now nearly half of my patients (since I've been practicing in Corvallis, Oregon for over 10 years, many of my patients are those who cannot get better and move on; they are improved, but still teetering on the brink of severe symptoms, often including suicidal thinking). My personal income from all my psychiatry activities, including the speaking fees, is no higher than it was when I was working for my local hospital as their employee and giving no talks at all. In fact, it is quite a bit less if you count health care and retirement benefits, even though I work more hours now, especially if you include writing time. [Update 2009: I am still on the speakers bureau for AstraZeneca, manufacturer of Seroquel. That's the only one left where I have no doubt about the effectiveness of their product, relative to the risks -- even though the risks are substantial.]
Hospitals have been doing this kind of thing for years, calling it "cost shifting": they make their charges high enough for insured clients to cover the costs of providing services to people who can't pay. I look at what I'm doing as a modern, slightly more indirect version of "cost shifting", in this case to one of the few in the mental health business that actually does have plenty of money -- the pharmaceutical companies.
Obviously there is a risk that I'm offering myself an elaborate rationalization for taking drug company money; for working less hard; for seeing fewer patients (the real work of psychiatry); and for having the ego gratification of giving presentations as the "invited expert". There is some truth to that. I don't think it's the whole story though, and it sure helps to know I have money coming from somewhere else when my patients can't afford what they need. For some specific examples of how the money and I dance together, see the next section.
As one final justification for my current way of doing things, I'd invite you to look at the series of mini-chapters on the genetic, molecular and cellular basis of depression. I think that is a substantial public service, paid for by the pharmaceutical companies, essentially. I hope very much that you will agree, if you read it. You are welcome to write and tell me what you think.
Okay, so how much money? Well, the companies don't like you to know. I have to sign an agreement not to tell, in fact. But let's just say I'm now getting substantially less per talk than I used to from one company that actually gave me, believe it or not, $2500 every time I spoke for them. Amazing, isn't it?
2. Is the money I receive likely to influence what I
say on this site and in public?
Good question. So far, I hope the answer is no. I still think I'm completely free to speak my mind in both settings. One company requires that I use their slides, which I summarize quickly noting that "this is what the manufacturer wants you to know". That leaves about 80% of the time for an open discussion based on participants questions and comments, focusing primarily on recent data on diagnosis. On issues of treatment I am restricted to comments relevant to the FDA indications that medications already have. For questions about "off label uses", my comments are brief and general, as required by the FDA. Overall, primarily because of these FDA rules, I admit that when I am talking for a pharmaceutical company, I am careful about what I say and how I say it.
As for the information on this website, you'll see that most of it is "referenced": there will be a link to the research on which any statement is based. You should wonder, though, if somehow the funding I receive is subtly shifting the entire information set: omissions you can't see, or including extra information on a specific product. See if you can find some evidence of bias on this site.
For example, see the comparison of all options on the Mood Stabilizers page, which I think is pretty clean regarding any biases. All the major good things and major bad things about each option are there, and I don't think I "spun" them much, certainly not by omission. Oh, one more thing: you might think I'm pretty hard on poor old olanzapine (Zyprexa). I admit to that. Their sales force tried to cover up the weight-gain problem far too long and I've yet to forgive them for that. But one does not have to try to make their product look bad, even though it is a great tool for some circumstances.
Finally, you might wish to read articles, full-text online, about the problem of the relationship between doctors and the pharmaceutical industry. The British Medical Journal, in May of 2003, devoted most of an issue to this subject. I read them closely to see if I'm missing anything in my attempt to watch out for this influence. Here's a fun excerpt from one:
Most patients' organisations are poor and have little independent funding. Grants from and joint projects with pharmaceutical companies can help them grow and be more influential, but can also distort and misrepresent their agendas. Relationships must therefore be fully acknowledged and open, without public relations flummery. [Flummery is a charming name given to various sweet dishes made with milk, eggs, flour, etc.; but also an empty compliment; unsubstantial talk or writing; mumbo jumbo; nonsense--!]
I still think I'm okay, but you'll have to be the judge. I am also aware that by trying to disclose all possible biases, as I've done here, I may be giving myself an excuse to continue to take the pharmaceutical companies' money! (what has been called "moral licensing" Cain ).