The article on the war over side-effect claims regarding atypical antipsychotic medications highlights some important issues concerning the pharmaceutical industry’s current role in our mental health care system. In that article, which is in the August 3 issue, Alan Brier, M.D., is quoted as saying that “patients and their doctors will speak with their prescription pads” when it come to choosing which antipsychotic medication is best for a particular patient. This statement is, in fact, only partially true. If pharmaceutical companies get to the individuals who determine which drugs are “formulary” and which ones are not, the deck may be stacked in favor of certain medications before physicians even get their pads out. As a psychiatrist employed by a large, federally funded institution, pharmaceutical company representatives have informed me that they meet regularly with individuals in the department of pharmacy in an effort to ensure that their products are available on the formulary.
I’d be interested in a study of pharmaceutical companies’ marketing efforts to pharmacists and individuals who head the departments of pharmacy and formulary in organizations such as VA medical centers, state departments of mental health, and managed care companies, all of whom are in position to affect the composition of formularies. During a conversation regarding the drop of a particular psychotropic medication from the formulary at our VA medical center (a decision in which our department had no appreciable input), a psychiatrist colleague of mine made the observation, “It’s their budget, not ours.” As long as formulary decisions are made by the people who “hold the purse strings,” psychiatrists’ ability to prescribe antipsychotic medications according to individual patients’ medical needs and clinical response will likely be hampered.
Later in the article, Ira Glick, M.D., does well by emphasizing the need for physicians to make these clinical choices, and for the choices to be made based on research data. Pharmacists, pharmaceutical representatives, and health care administrators do not have adequate expertise to make the sorts of clinical distinctions necessary to select the proper antipsychotic medication for a particular clinical case or clinical subtype. This article reminds us that we need to monitor the marketing efforts of for-profit organizations such as pharmaceutical companies and to view these efforts with caution.
