Tuesday, October 07, 2008

Thoughts on Charles Nemeroff's Not So Excellent Adventure

The saga of Dr Charles Nemeroff was most recently discussed on Health Care Renewal here. We had first posted about his failure to disclose relevant conflicts of interest relating an article he wrote for a journal he also edited here. Other posts about Nemeroff's questionable behavior are here, here. Nemeroff has also starred in numerous posts on the Clinical Psychology and Psychiatry Blog, amongst others.

Now the tale of how Nemeroff raked in hundreds of thousands of dollars as a paid speaker on behalf of drug marketers, and denied these earnings while he ran a US government funded project meant to evaluate some of the products of his commercial sponsors, has splashed across major newspapers. There has been a lot of good discussion about the case in the blogsphere. (We await, of course, discussion in scholarly medical and health care journals, if it ever appears.)

I did think it was worth weighing in again just to underline some important points about this affair.

It has become common for academic leaders to earn more hawking commercial products than from teaching, research, or patient care. The database unearthed by Senator Grassley just of the speaking fees earned by Dr Nemeroff giving speeches promoting GlaxoSmithKline products is breath-taking. As noted by the anonymous blogger on the Clinical Psychology and Psychiatry Blog, Nemeroff was earning on average more than $20K a month from GlaxoSmithKline alone. That was from only one company. As that blogger also noted, Nemeroff at one point was a consultant for 18 companies, if I counted right, and gave paid talks for 4. Here is the actual relevant part of the disclosure statement.

[Nemeroff] has been a consultant to Abbott Laboratories, Acadia Pharmaceuticals, Bristol-Myers Squibb, Corcept Therapeutics, Cypress Bioscience, Cyberonics, Eli Lilly and Co, Entrepreneur’s Fund, Forest Laboratories, Inc, GlaxoSmithKline, i3 DLN, Janssen Pharmaceutica, Lundbeck, Otsuka America Pharmaceutical, Inc, Pfizer Pharmaceuticals, Quintiles Transnational, UCB Pharma, and Wyeth-Ayerst Laboratories; has been on the speakers bureau for Abbott Laboratories, GlaxoSmithKline, Janssen Pharmaceutica, and Pfizer Pharmaceuticals;

At most medical schools, bringing in money is more important than academic integrity, or anything else. We have previously posted about how one medical school leader explained that faculty who are "taxpayers," that is, bringers of money, are more valued than all others.

The case of Nemeroff shows how big-time taxpayers are now above the law at medical schools. As Dr Howard Brody explained it on the Hooked: Ethics, Medicine and Pharma Blog

[Nemeroff] sent a confidential letter to the dean of the medical school at Emory in May 2000, listing the dozen corporate advisory boards in which he sat. He then ticked off the grants and endowments that those firms had paid to the Department of Psychiatry at Emory, and added, 'Part of the rationale for [the companies'] funding our faculty in such a manner would be my service on those boards.' Translation--you mess with my cozy relationships with these companies, and the industry gravy train to Emory dries up. The threat is only slightly veiled, that should Emory decide to take any serious action against Nemeroff for his unreported conflicts of interest, he could easily jump ship to a more permissive med school, taking a lot of his captive research faculty and all of his industry funding with him.

Lying is an acceptable way to maintain an academic medical leadership position. Senator Grassley's letter to Emory documented this instance:

On several occasions during the life of this grant, it appears that Dr. Nemeroff
failed to report to Emory that he was participating actively on the speaker’s bureau for GSK. For instance, in an email regarding his outside activities dated October 1, 2003, Dr. Nemeroff wrote:
'…I have to dig up the agreement and send it to you, GSK no standing
contract, I chair their ad board 2-3 times per year and I am paid per board
meeting at a standard rate of $5K per weekend
However, and based upon information in our possession, in 2003 GSK
paid Dr. Nemeroff about $119,000 in speaking fees and expenses

$15,000 does not remotely equal $119,000. Stating he was paid the former when he was paid the latter goes beyond "misspeaking."

Bullying helps too. As Dr Brody put it,

Nemeroff is pleased to bear the nickname 'Boss of Bosses.' He has a reputation for wielding tremendous power in psychiatry, especially taking advantage of his leverage with the big drug firms, and is ruthless in attacking those whom he doesn't like or who threaten him. One such event is described in some detail in HOOKED, the hiring and then subsequent firing of David Healy as head of a psychiatric research institute at the University of Toronto, due to Healy saying bad things about Prozac, whose manufacturer, Eli Lilly, was at the time considering a major grant to Toronto. Healy cheerfully sued Toronto and won, meaning that all the correspondence related to the firing is now in the public domain. In HOOKED I focused on Toronto's spineless behavior, but it is also interesting to note that almost certainly, Nemeroff was in the background pulling all the strings that led to Healy's dismissal.

Not only was this a case of bullying, of course, but it was also a case of the trampling of academic freedom, in this case, apparently to support the continuing relationship between pharmaceutical companies, "key opinion leaders," and medical schools, so profitable to these parties, but so detrimental to the integrity of academic medicine and of the clinical research data base.

The case of Charles Nemeroff's not so excellent adventure illustrates the sorry current state of the leadership of academic medicine. As Dr Brody put it,

In today's world, a medical school like Emory looks at all the pluses and minuses of having a guy like Nemeroff as a powerful chair, and decides that the pluses outweigh the minuses. His publication record is stellar (mostly ghostwritten of course), he brings in huge research grants, and people in his specialty all over the world want to kiss the hem of his garments. What has to change, in the regulation and the culture of the academic medical center, so that it becomes a no-brainer that having a guy like this on your faculty is a net loser?

Without such change, the public will fairly start to judge academic medicine's integrity as only slightly better than that of the garbage hauling industry, and that may be too insulting to the garbage hauling industry. It is sad beyond words that the current leadership of these once proud institutions have lead them to this pass, just for a few dollars more.

ADDENDUM (8 October, 2008) - See also comments by Dr Daniel Carlat on the Carlat Psychiatry blog here and here, and by Alison Bass on the Alison Bass blog here.


Anonymous said...

WOW! At some point you want to throw away all this nice academic veneer and simply ask: What is going on? At least when the guy with the bent nose shows up to talk trash hauling you know what is going on.

I personally believe that very few situations are unique. You do not need to be a doctor to see the explosion of life long therapies due to "new" better standards. The real issue becomes: What were the financial incentives for mandating these new standards?

What this issue does do is call into question all, all, of the current standards. Doctors need to be more skeptical than ever of any new drug or therapy. This can be difficult when the front line doctors themselves are being offered financial incentives to prescribe a new drug. The snake oil salesman of old has reemerged, only this time he wears a suit, and holds an academic position.

Steve Lucas

Anonymous said...

This week the Chairman of my department at Emory, Charles Nemeroff, M.D., Ph.D., got caught up in a a broo-ha-ha about unreported earnings from outside activities related to giving lectures that were supported by the pharmaceutical industry. This led to his resignation pending the result of an inquiry into the allegations raised by Senator Charles Grassley. Mind you, I am not here to justify Dr. Nemeroff's bad behavior. To not disclose the payment of more than $10,000 a year from a drug company that makes a drug you are also studying with an NIH funded grant is clearly a violation of NIH policy (although not a violation of the law).

Nevertheless, I have some questions for the Senator.

First off, why are you only investigating psychiatrists? [Answer: psychiatrists have an approval rating in medicine that is only above chiropractors. Many people blame paxil for their problems. It is low hanging fruit]

Second, why don't you look at other specialties? Take a look at cafepharma.com, where the drug reps are gossiping in relation to the Nemeroff dispute that "key opinion leaders" for advair are at the front of the gravy train. [Answer: cardiologists make life saving drugs, while psychiatrists are pseudoscientists who are trying to invent a myth about serotonin imbalance so they can help sell drugs for their cronies, the drug companies.] [Answer to answer: Not true. You have to treat 100 heart disease patients with Lipitor to prevent one heart attack, while you treat only 8-17 depressed patients with an antidepressant to prevent a recurrence. And if you don't believe that depression is as bad as a heart attack, ask someone who has been there.]

Ask anyone who works in a university hospital. If their docs have any talent, they are never there. It is because they are always away giving talks for pharma. And pretty much all of it is undisclosed. Not to try and justify it, but lets get real.

Finally, I came under full frontal attack for my opinions about accutane and depression that went against pharma and for which they tried to ruin my career, and the ONLY person at Emory to stick up for me was Nemeroff. You can read about it on my web site.

Senator Grassley, if you really want to get to the bottom of the corruption that has permeated academic medicine, do a nation wide audit. Of ALL specialties. If you don't, you are a hypocrite.


Roy M. Poses MD said...

First, please note that on Health Care Renewal we have written about many specialties and sub-specialties, about health professionals other than physicians, and about many kinds of organizations other than pharmaceutical companies and academic medical centers.

I obviously cannot speak for Senator Grassley.

Whether the behavior of academic psychiatrists is worse than that of other academic specialists I cannot say. But it certainly does seem to present some low-hanging fruit for anyone interested in investigation of conflicts of interest and their effects on academia.

Note also that there now seems to be very good evidence that results of clinical trials of anti-depressants which were unfavorable to the drugs made by the companies who sponsored the trials were suppressed. See the paper by Erick Turner et al. Therefore, using the efficacy of anti-depressants as an example may not be a great idea.

It is true that the data show that the majority of academic physicians get payments from pharma, biotech, or device companies. And these companies assert that these physicians are the best and the brightest. But there is also some evidence that these companies cultivate physicians as "key opinion leaders" who are most likely to help them with marketing, not because of their brilliance. Because these companies start supplying these physicians with grants and speaking engagements early in their careers, and because getting ahead in academics now depends mainly on how much money one brings in, such physicians may quickly become academic successes, but not necessarily based on their abilities or brilliance as teachers or researchers.

I'm glad Nemeroff stuck up for Dr Bremner, but Nemeroff also seemed implicated in the firing of Dr David Healy from the job he never got to start at the University of Toronto. So his inclination to stick up for dissidents is not exactly clear.

Anonymous said...

I agree that pharma acts as king makers for thought leaders in psychiatry, getting them front and center at association meetings, and promoting their publication records by providing editorial help, or by ghostwriting. I was dropped from the pharma lecture circuit several years ago. I think it is because I refused to show slides that were picked out for me. I was told that the FDA had to approve their slide sets in advance. I would like to know if this is really true. I was also told that they have to cover themselves from people talking about off label use of medications. I continue to maintain that if you want to provide education, pay a professor to give a talk, and then let him show his own damn slides. Here is another example. I gave ground rounds last year at another university and was told that the dept had to scramble to come up with the financing because the drug company that financed grand rounds had a list of speakers they would approve, and I wasn't on that list.

I continue to maintain that Senator Grassley is unfairly focusing on psychiatry. If he is not, let's see him look at some other specialties, like cardiology. I have an open letter to him on my web site. Let the sun shine in, Senator.

Anonymous said...

Dr. Nemeroff, and I speak from direct professional experience, is a "scientist" whose research objectives were to prove that which he believed to be true, not to objectively evaluate formal hypotheses. Simply put he was obsessed with finding the "cure" to "the" plague of depression.

He became the god of CRF (corticotrophin releasing factor) research because he was CERTAIN that this was THE answer to THE disease. Never did I see a doubt that "depression" may be many diseases with many etiologies. He is not and likely never was a scientist. He is simply a demagogue who pursues a single truth. Along the way, he found that the passion for power was equally great.

In pursuit of his obsessions, he has interfered with the careers of others, exerted profound influence on the funding of NIMH grants in the area and the entire federal funded direction of research, and perhaps influenced the choice of the current director of NIMH. He has both whored himself to the pharmaceutical companies and threatened them to get his way (yes, he has garnered that much power).

Poor Charley, in his heyday, he could rent out the San Diego aquarium and the Philadelphia Museum of Art for opulently subdued get-togethers at the annual Neuroscience meetings funded by big-pharma. Find your own sources for how opulently! Emory squelched that, but like all others in his path, caved to his power with respect to his more egregious, if less blatantly illegal, activities.

Even now, he has only "provisionally" resigned his chairmanship. He has the full standing, privileges and salary of his faculty position (yah, yah, that salary pales beside his pharm payola).

We'll never know how much his monomania has cost us - in delays in progress toward better diagnosis and treatment of depression and in the very function of the clinical research basis of psychiatric treatment.

All that I can say is that if you, as I did, ever see a 40 year-old "scientist" with a 10 pound resume claiming 450 peer-reviewed publications, decry him as a liar and keep a great distance.

Anonymous said...

Medicine has been criminalized. We are the targets of everyone. We are the training ground for every type of investigator training school. This is because there is no medical profession now 36 years after Roe v. Wade...as we are cursed without the Oath of Hippocrates (just as it states we would be so cursed). Thus there is alot to investigate too. The doctor patient relationship has been replaced by the doctor insurance company relationship as we collaborate with health insurance companies which are frauds stealing over $600 billion health care dollars (more than the defense budget)yearly as administrative costs ("profits" to them). And the AMA does not give a damn as doctors galore sell out to politicians, lawyers, and other pimps for the health insurance industry which ought to formally take over all medical schools. Finally, our best friends, our only friends, are the pharmaceutical companies. Serves us right. A lot of doctors deserve what happens to them...they never cared about The Oath anyway. Samuel A. Nigro, M.D., Psychiatrist

addie said...

After extensive research Dr Nemeroff was proven completely innocent of the allegations made by this POLITICIAN, who like the people posting here and some commenting, seem not find facts very important, Shocking, isn't it?

If any of you knew anything you would be embarrassed to visit this topic again until you know what you are talking about.

"Anonymous," are you that person, who blames Dr, Nemeroff for the loss of thier job over 20 years ago and has shown obvious anger about that ever since, causing discomfort and confusion for many people?
You sound that that nutter because no one who knows the Doctor, really, would say what you have said, the support he has gotten form the medical community and academic as well, speaks for itself.
Get help already!