Wednesday, February 04, 2004

Hell Freezes Over; Otters Defend Big Pharma

I've done my fair share of bashing the pharmaceutical industry. And at first glance, this article in the New York Times seems to provide fodder for more of the same.
To sell medicines that treat schizophrenia, [drug] companies focus on a much smaller group of customers: state officials who oversee treatment for many people with serious mental illness. Those patients - in mental hospitals, at mental health clinics and on Medicaid - make states among the largest buyers of antipsychotic drugs. [...]

Since the mid-1990's, a group of drug companies, led by Johnson & Johnson, has campaigned to convince state officials that a new generation of drugs - with names like Risperdal, Zyprexa and Seroquel - is superior to older and much cheaper antipsychotics like Haldol. The campaign has led a dozen states to adopt guidelines for treating schizophrenia that make it hard for doctors to prescribe anything but the new drugs. That, in turn, has helped transform the new medicines into blockbusters.
After eleven paragraphs of marketing description, and at the bottom of the first page of the web story, we are told that the novel antipsychotics cost around $3,000 a year, compared to the $250 annual cost of an older antipsychotic. And yet states are mandating that the newer drugs be prescribed! This is obvious graft, right?


In the 19th paragraph there is a brief mention that "doctors widely prefer the new medications, saying that the older drugs cause a higher incidence of side effects like stiffness, trembling and uncontrollable jerks that can stigmatize patients and prompt them to stop taking the drugs." This is immediately countered by the claim, in the following paragraph, that the new drugs can increase the risk of obesity, diabetes, and high cholesterol - so comparatively, "stiffness and trembling" seem like minor complaints.

But what they're talking about when they say "trembling" is tardive dyskinesia, a form of irreversable nervous system damage. Tardive dyskinesia causes tics and twitches which may happen dozens of times an hour, which may be disfiguring, and which are almost always awkward and uncomfortable. Twenty percent of people with schizophrenia develop incurable neurological damage within five years of beginning traditional antipsychotics, and the risk increases with the duration of treatment. So in the old days, almost every chronic schizophrenic wound up with some symptoms of TD. With the new, expensive drugs, the risk of TD is ten times less.

The increased risk of diabetes with the new antipsychotics, which appears to have been included in the article for "balance," doesn't seem particularly comparable. There is a significantly greater relative risk of diabetes in people on the new antipsychotics - they're 1.17 times more likely to develop diabetes than people on the older versions. But the overall risk of diabetes in schizophrenics isn't particularly high - the incidence is only 2.5%. (Reference here; requires free registration.) So we're talking about moderately increased risk of a treatable, not-very-common side effect - compared to vastly increased risk of an incurable, common side effect, in the case of TD.

Now, the article appeared in the NYT's business section, not the medical section - so I suppose I can't expect the reporter to go through and figure out the business about relative risks and so forth. But it still seems to me that the article has an obvious slant. If you ask psychiatrists, nine out of ten will immediately tell you that the newer drugs are much better for the patient. But that doesn't come through in the article at all. Who'd the reporter talk to?