Wednesday, August 19, 2009

High Costs and Poor Outcomes - A Lesson About the Suppression of Research

Last week, blogger Alison Bass was one of the few to comment on a new article on the risks of antidepressant medications published electronically last week by the British Medical Journal.[1] The article adds to the clinical evidence about these specific drugs. However, it also should remind us about why our health care costs seem to continue to inflate disproportionate to any improvements in health care outcomes.

Background - Why Don't Doctors Diagnose and Treat Depression According to the Evidence?

Here is the background. Since the early 1990s, based on numerous published clinical trials that showed that the newer (mainly SSRI, that is, selective serotonin reuptake inhibitor) antidepressants seemed to be quite safe and effective, authoritative guidelines have urged physicians to screen patients for depression, and have a low threshold for beginning treatment, particularly with these then new drugs. (For example, see the 1993 AHCPR guidelines,[2] and the Ambulatory Care Quality Alliance Recommended Starter Set[3].) Such guidelines targeted primary care physicians as well as psychiatrists. As a primary care physician, I often felt guilty that I didn't screen all patients, including those who did not outwardly appear depressed, for depression, and was reluctant to be the primary prescriber of antidepressants for depressed patients. I was not alone. There was evidence that many primary care physicians failed to follow these apparently evidence-based guidelines.

Suspicions that SSRIs Were Not as Effective or Safe as Thought

However, in 2004, internal documents from one drug company (Glaxo Smith Kline), published by the Canadian Medical Association Journal, suggested that the company had suppressed a study which failed to show its SSRI was effective for adolescent patients.[4] Also, then New York state attorney general Elliot Spitzer sued the company alleging it had suppressed such data.[5] Considerable anecdotal information thereafter came to light suggesting that drug companies may have suppressed data from clinical research (that is, studies done on patients, not in the laboratory) which tended to show the drugs were less effective, or more dangerous than previously thought. Many began to suspect that the drugs increased the risk of suicidal thoughts or behavior, even though one would think that if they were effective in treating depression, they should decrease such risks.

How Does Uncovering Suppressed Trials Change the Evidence About the Benefits and Harms of SSRIs?

Then, an analysis of trials of SSRIs given to adolescent patients, which included unpublished as well as published trials, did show they increased the risk of suicide.[6] But what about adult patients?

In 2008, Erick Turner and colleagues published a meta-analysis that included numerous trials of SSRIs and other antidepressants given to adult patients that had never been published, but whose results had been submitted to the US Food and Drug Administration (FDA).[7] When those trials were included in the analysis, the drugs seemed less effective than was previously believed.

The new meta-analyis by Stone et al[1] suggested how adding evidence from the suppressed trials improves our knowledge about the possible harms of these drugs. Stone et al specifically addressed whether the drugs increased the risk of suicidal thoughts or actions for adult patients. It was based on data from 372 trials that included 99,231 patients. "Most of the studies were unpublished; those that had been published in some form seldom contained information concerning suicidality in the publication." Its main result was that SSRI drugs approximately doubled the risk of suicidal behavior for patients less than 25 years old, but decreased the risk for older patients.

Suppressing Trials Distorted the Evidence-Base

Thus, the combined results of several meta-analyses suggests that SSRIs are neither as safe nor as effective for adult patients as they were previously touted to be. The drugs used to appear to be more safe and effective because the drug companies that sponsored (paid for) clinical trials of their own products suppressed the publication of studies whose results did not show their products in a favorable light. The guidelines once thought to be so authoritative are probably much to enthusiastic about the use of drugs to treat depression. It may be that those physicians who resisted pressure from these guidelines and other efforts by would-be quality improvers to diagnose more depressed patients and treat them with SSRIs weren't so dumb.

Health Policy Implications

The recently published meta-analysis of the risk of suicidal ideation or behavior due to SSRIs for adult patients[1] adds not just to the clinical evidence about the treatment of depression, but to the evidence that suppression of research by those with vested interests in its results may not be rare. There is no reason to think that suppression of research about other medical interventions used for other clinical problems does not occur just as often.

This underscores why we as a society should not have handed over control of how new drugs and devices are evaluated to the companies that stand to profit by selling them. The apparent benefits and safety of most drugs and devices brought to the market in recent years may have been exaggerated by the ability of the corporations who sponsored the research to suppress those studies that were least favorable to their products. Thus, it is very likely that doctors have over prescribed newer (and more expensive) drugs and devices based on erroneous beliefs about their safety and effectiveness, beliefs supported by an evidence base which was distorted by suppression of studies whose results did not show the results their commercial sponsors wanted to see. Furthermore, we have likely collectively paid too much for these drugs and devices based on these same erroneous beliefs. Thus, the distortion of the clinical evidence base caused by putting the makers of medical products in charge of their evaluation has likely led to increased costs and worse outcomes for patients.

Health care reformers serious about wanting to improve patient outcomes and reduce costs ought to be at the forefront of a movement to make clinical research more honest. All clinical trials completed and submitted to government regulators ought to be published in some form, so that the data they contain is available to guide clinical decisions. Going forward, all studies should be published in some form in a timely manner to prevent future research suppression. There ought to be better regulation of research sponsored, and de facto run by companies who have vested interests in the results being favorable to their products. It would not be unreasonable to prevent companies with such vested interests from running or otherwise directly influencing clinical research meant to evaluate their own products.

But here in the States, we are probably too diverted by yelling at each other about whether a "public option" is vital or nefarious to worry about such issues.. Meanwhile, expect our health care to continue to get more expensive, less accessible, and less good for patients.

ADDENDUM (25 August, 2009) - Also, see the comments by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma Blog

References

1. Stone M, Laughren T, Jones ML et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. Brit Med J 2009; 339: b2880. Link here.
2. Depression Guideline Panel. Depression in Primary Care: Volume 2 - Treatment of Major Depression. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993. Link here.
3. Ambulatory Care Quality Alliance. Recommended Starter Set: Clinical Performance Measures for Ambulatory Care. http://www.ahrq.gov/qual/aqastart.htm
4. Kondro W. Drug company experts advised staff to withhold data about SSRI use in children. Can Med Assoc J 2004; 170: 783. Link here.
5. Wadman M. Sptizer sues drug giant for deceiving doctors. Nature 2004; 429: 589. Link here.
6. Hammad T, Laughren T, Racoosin JA. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-9. Link here.
7. Turner EH, Matthews AM, Linardatos E et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358: 252-260. Link here.

3 comments:

MedInformaticsMD said...

As I commented in an earlier post on ghostwriting, the distorting of the scientific evidence base may have created a cadre of honest "experts" whose expertise is unknowingly (by them and by others) tainted by these abuses.

Bernard Carroll said...

Well said, Roy.

Regarding the prices of new antidepressant drugs, part of the problem lies in the so-called discipline of pharmacoeconomics.

Not only are the makers in charge of evaluating their products, they are also in charge of pricing those products. By a combination of disease mongering, suppression of evidence of inefficacy, suppression of evidence of toxicity, off-label happy talk, and hardball promotion, they maximize the potential market. Adding insult to injury, they then claim predatory levels of pricing, which they justify by reference to the distorted claims of efficacy and safety. And then they have the gall to claim pre-emption from litigation when the bodies start to drop.

All those vaunted QALYs of claimed benefit have shuffled off to some kind of health economists’ limbo, waiting for the trumpet of the next breakthrough – broad spectrum psychotropic drugs like the atypical antipsychotics, perhaps? God help our depressed patients, who will be fleeced for the privilege of developing akathisia and tardive dyskinesia.

Anonymous said...

Two words come to mind: Emory University.

While watching some of what passes as "news" I was struck by the statements of a medical doctor, with known extensive ties to industry, Scott Gottlieb, who basically stated there are no unnecessary test, medications or procedures done in the US. All doctors follow strict clinically proven guidelines.

How does one make the point the guidelines are designed with the intent of maximizing drug company profits, not helping patients?

Steve Lucas