Evelyn Pringle February 12, 2008
GlaxoSmithKline recently received greetings from a Congressional Committee, asking the company to explain the findings in a report unsealed last month in a lawsuit which shows that Glaxo knew as early as 1989 that Paxil increased the risk of suicidal behavior in patients by more than 8-fold compared to patients who received a placebo.
In a February 6, 2008 letter, Senator Charles Grassley (R-Iowa), ranking member of the Senate Finance Committee, is asking Glaxo to explain why the American public was never adequately informed of this risk until May 2006 in a "Dear Healthcare Professional" letter which reported a "higher frequency of suicidal behavior" associated with Paxil as compared to placebo.
The report showing the 8-fold suicide risk, by Harvard instructor and psychiatrist Joseph Glenmullen, was unsealed on January 18, 2008, by a federal judge in a US District Court in Sacramento, California in the Paxil suicide case of O'Neal v SmithKline Beecham d/b/a GlaxoSmithKline, filed by the surviving family members of 13-year-old Benjamin Bratt.
Dr Glenmullen was retained as an expert in the case by the California-based Baum, Hedlund, Aristei & Goldman law firm.
On January 30, 2008, the court dismissed the lawsuit on the basis of the Bush Administration's new preemption policy, largely unknown to most Americans, which says that once the FDA approves a drug and its label, citizens may not sue a company for failing to warn about a risk not listed on the label, even in cases like this where the plaintiff can prove that the company knew about the risk and intentionally concealed it.
SSRI's are antidepressants known as selective serotonin reuptake inhibitors and include Paxil, Eli Lilly's Prozac, Zoloft by Pfizer and Celexa and Lexapro marketed by Forest Labs. Wyeth's Effexor, Lilly's Cymbalta and Glaxo's Wellbutrin are not considered SSRI's, but they also carry a warning about an increased risk of suicidality in young people.
Two SSRI suicide cases are now awaiting a joint decision from the Third Circuit Court of Appeals for which oral arguments took place in December 2007.
In the case of Colacicco v Apotex, the US District Court for the Eastern District of Pennsylvania was the first to dismiss a failure-to-warn claim based on the new preemption policy, and in McNellis v Pfizer, the US District Court for the District of New Jersey found no preemption.
Also unbeknownst to most Americans, the Bush Administration is instructing judges to dismiss the lawsuits against the SSRI makers in amicus briefs filed by the government's top attorneys, who also attend hearings when necessary to argue on behalf of the SSRI makers during oral arguments on motions to dismiss.
In fact, in regard to requiring a warning about suicide, during oral arguments in the Third Circuit, Bush Administration attorney Sharon Swingle told the court that the FDA "had again and again and again made an expert determination that the warning was not appropriate."
She maintained that the claims were preempted because the SSRI makers were not allowed to add warnings to the label under any circumstances without prior approval from the FDA.
At one point, the court asked an attorney for an SSRI maker, "assume for the moment that you had reasonable evidence of an association between your product and a serious hazard or a serious possibility of an enhanced suicide risk."
Under federal regulations, "what would be your obligation?"
The attorney stated, "our obligation would be to take that information to the FDA, advise the FDA of the information."
"It then would be the FDA's determination whether that represented a substantial relationship," he told the court.
"So if you had evidence internally that there's an enhanced risk of suicide, you would go to the FDA," the court said, and asked, "And how long would that take?"
"I do not know the answer to that, your Honor," the attorney said, and the court asked, "Could it take months?"
"I imagine it would depend on the seriousness --," the attorney stated.
"But isn't there a significant possibility that additional people then might have the same consequence that happened here with McNellis, or with Colacicco and McNellis's father?" the court asked.
The attorney said, "on the basis of the information that was available we would take it per FDA directive to the FDA and they would make the determination whether the label should be changed."
"Other people could then," the court continued, "possibly have an enhanced risk of suicide and other people may commit suicide as a result of taking your product?"
"We would be bound by law to comply with the FDA, then to comply with its directives," the attorney replied.
"Are they requiring that you go through them first rather than act on your own?" the court asked.
"That's exactly correct, your Honor, because there is the bigger issue of the --" the attorney stated.
However, at the end of the hearing, Pennsylvania attorney Derek Braslow proved beyond any doubt that the claims made by the Bush Administration attorney and the attorneys for the drug makers were blatant lies, when he informed the court that Glaxo had "independently, strengthened their warning in May 2004 to warn about increased suicidality and worsening depression in everyone, not just children."
"There was specifically in bold letters a new warning with respect to increased suicidality and worsening depression in May 2004," he stated.
"Glaxo changed the label on their own without FDA approval," Mr Braslow told the court.
Glaxo did it again in May 2006, he said, when they sent out a "Dear Healthcare Professional" letter and warned about the increased risk of suicidality and suicidal behaviors with Paxil in persons of all ages.
During oral arguments in the O'Neal case on January 21, 2008, Glaxo's preemption argument was presented by King & Spalding attorney Mark Brown, who just happens to be a former Associate Chief Counsel for the FDA from the first Bush Administration.
The family intends to ask the court to reconsider the ruling in the O'Neal case, according to a statement by Baum Hedlund.
In his report, Dr Glenmullen sums up the inadequacy of the system, including the FDA, that allowed Glaxo to keep this vital information hidden from prescribing doctors and patients for nearly 2 decades and states, in part:
"One of the most sobering aspects of the story of Paxil-induced suicidality is that GlaxoSmithKline was not forthcoming with its data demonstrating the risk and regulatory agencies like the FDA did not take the initiative to get to the bottom of and expose the true risk."
"Rather, the impetus came from attorneys and medical experts surprised by what they found in GlaxoSmithKline's confidential documents, which only came to light through litigation."
"The GlaxoSmithKline documents that have so-far made it into the public record have in turn been critical to educating patients, the public, and the media about the true risk. The media - particularly the BBC in England - played a crucial role in turning the tide in the history of Paxil-induced suicidality."
According to Dr Glenmullen, "it was the diligent efforts of plaintiff's attorneys that forced GlaxoSmithKline to divulge the inaccurate counting method to the FDA."
Another leading expert on pharmacology, Dr Peter Breggin, warns that an 8-fold increased risk of suicidality in controlled clinical trials could mean 80-fold in actual practice. "We can't determine exactly how much greater the risk will be in clinical practice but it will be astronomically greater," he advises.
In actual practice, he explains, many patients are already suicidal when they start taking the drug, increasingly the likelihood that the drug can push them over the edge.
Despite the warnings to watch patients closely, Dr Breggin says, busy doctors do not monitor patients properly. He explains that they are almost never evaluated for suicidality and are often given multiple drugs at the same time, by doctors who know little about their adverse effects on the mind.
Glaxo is facing lawsuits from surviving family members of Paxil suicide victims all over the country and is attempting to use preemption to avoid public trials for good reason. The first case to go before a jury in Wyoming in 2001, involved a man who shot his wife, daughter and infant granddaughter before shooting himself after being on Paxil for just a matter of days.
The trial resulted in a verdict against Glaxo for $6.4 million after the jury weighed the expert testimony of famed pharmacologist Dr David Healy, who presented a summary of Glaxo's hidden suicide data on Paxil, against the testimony of the industry-funded SSRI defender Dr John Mann, whose name appears on many of the studies issued over the years, some as late as 2007, that steadfastly proclaim that SSRI's are not linked to suicide and should be prescribed to children.
In addition to Dr Healy's revelations about hidden data showing that Glaxo was aware of the increased risk, Dr Mann's credibility was likely weighed against the fact that he had received over $30 million in research funding from drug companies between the early 1990's and the trial in 2001, which was brought out during his testimony by Houston attorney Andy Vickery.
Mr Vickery also established that, roughly 10 years and $30 million earlier, Dr Mann had published a paper stating that SSRI's could increase suicidality in a small subset of patients.
In his report, Dr Glenmullen states that, since Glaxo had the original data in 1989 that showed a greater than eightfold increased risk, it should have warned doctors and patients about the risk "a decade-and-a-half ago when Paxil was first approved by the FDA."
The report includes portions of an April 29, 1991 report, written by Glaxo psychiatrist Dr Geoffrey Dunbar, sent to the FDA in response to a specific request for information on suicidality in which Glaxo openly lies in stating: "analyses of our prospective, clinical trials for depression show that patients who were randomized to Paxil therapy were at no greater risk for suicidal ideation or behavior than were patients randomized to placebo or other active control therapies."
Dr Glenmullen notes the importance of the date that this false data was submitted because the FDA had scheduled a hearing with a nine-member advisory panel for September 20, 1991, to discuss concerns raised a year earlier about the possibility of Prozac making patients suicidal. Paxil was not approved for use in the US until December 2002.
In his report, Dr Glenmullen points out that 5 of the 9 members on the advisory panel had conflicts of interest with drug makers and that 2 psychiatrists, Dr David Dunner of the University of Washington in Seattle and Dr Stuart Montgomery from England, had done research on Prozac for Eli Lilly, and later played crucial roles in Glaxo's publishing of what he calls "bad" suicide numbers in the Paxil story.
Dr Glenmullen's report includes portions of a September 19, 1991, memo distributed to over 20 senior staff the day before the hearing with a "Statement to be used to respond to inquiries re Paxil/Suicide," which claims explicitly that during GlaxoSmithKline's studies: "the incidence of suicide was lower among patients receiving Paxil than among those receiving placebo."
This was the statement the company ordered employees to make, even though 5 patients on Paxil committed suicide while no patients in the placebo group did. In addition, Dr Glenmullen points out that, up to 1989, seriously suicidal patients were excluded from Glaxo's studies, and therefore "anyone who became seriously suicidal during the studies only became so after being given Paxil or a placebo."
Yet the actual numbers show that there were 40 suicide attempts in the clinical trials by patients taking Paxil compared to 1 suicide attempt in the placebo groups.
Despite the poor quality of the data available to the advisory committee, and despite the many conflicts of interest of its members, one third of the members still voted for a warning in 1991, Dr Glenmullen points out.
Three months later, in December 1991, Dr Dunner, together with Glaxo psychiatrist Dr Dunbar, presented Glaxo's Paxil data with the "bad" numbers at a meeting of the American College of Neuropsychopharmacology (ACNP) in Puerto Rico.
During the presentation, the doctors told the ACNP: "Suicide and suicide attempts occurred less frequently with Paxil than with either placebo or active control," according to the Glenmullen report.
The ACNP's members are considered prominent academic psychiatrists who specialize in pharmacology, and the group has issued a number of position papers over the years which consistently denied a link between SSRI's and suicidality.
Dr Mann led an ACNP task force which included Dr Fred Goodwin, Dr Charles O'Brien and Dr Robinson, which supposedly reviewed all the clinical trial data on SSRI's and issued a consensus statement with the position that SSRI's did not increase the risk of suicidal behavior, which was published in the journal Neuropsychopharmacology in 1993.
In March 1995, Dr Dunner, Dr Montgomery and Dr Dunbar published the paper, "Reduction of suicidal thoughts with paroxetine in comparison with reference antidepressants and placebo," in the European journal Neuropsychopharmacology. This paper included a table with the "bad" numbers and claimed that other antidepressants were more likely to increase the risk of suicide than Paxil.
The paper specifically states: "Consistent reduction in suicides, attempted suicides, and suicidal thoughts, and protection against emergent suicidal thoughts suggest that Paxil has advantages in treating the potentially suicidal patients."
On July 5, 1995, Glaxo's marketing department issued a memo urging its sales force to use the Dunner-Dunbar paper to reassure doctors who were concerned over Paxil-related suicide that there was no need for concern.
The fact is, documents obtained in litigation prove that the FDA has known about the suicide risks of SSRI's for roughly 23 years. Two years before Prozac was approved, in May 1985, the FDA's chief investigator, Dr Richard Kapit, wrote: "Unlike traditional tricyclic antidepressants Fluoxetine's profile of adverse side effects more closely resembles that of a stimulant drug than one that causes sedation."
"It is Fluoxetine's particular profile of adverse side-effects which may perhaps, in the future give rise to the greatest clinical liabilities in the use of this medication to treat depression," he noted.
Dr Kapit's review described data from 46 clinical trials with a total of 1,427 patients and under the section, "Catastrophic and Serious Events," he listed 52 cases of "egregiously abnormal laboratory reports which were the reason for early termination," and "additional adverse event reports not reported by the company were revealed on microfiche."
"In most cases," he wrote, "these adverse events involved the onset of an unreported psychotic episode."
There were ten reports of psychotic episodes including 2 reports of completed suicides, 13 attempted suicides, 4 seizures, and 4 reports of movement disorders. In 1985, Dr Kapit recommended "labeling warning the physician that such signs and symptoms of depression may be exacerbated by this drug".
When Prozac was approved, no such warning was issued.
Two weeks after the FDA advisory panel met in February 2004 to review the data on SSRI's to determine whether they were linked to suicide, Dr Healy sent a report to Peter Pitts, Associate Commissioner for External Relations, at the FDA, in response to an invitation by Dr Robert Temple for a submission of the details of studies referred to in the course of a presentation at the meeting.
"A great number of the patient testimonies in the course of the Feb 2nd hearing were from individuals who became suicidal on an SSRI when their underlying disorder was Lyme Disease, migraine or a condition such as social phobia," Dr Healy pointed out.
He also noted that this had been the case in the 1991 hearings, when it was framed by FDA's Dr Temple as follows:
"The discussion we heard earlier showed that people who commit suicide are highly likely to have a diagnosis of depression, which means that somebody identified them as in a high-risk category. But there were still a significant number of people who committed suicide without having that sort of diagnosis and I guess I would like some advice or discussion on who those people were."
"The anecdotes that one hears that are most evocative to me anyway are not the ones where people who have a 20-year history of suicidal ideation and then finally do it - that is not too surprising - it is where they assert that there has never been anything in their minds like that before and yet now they have suddenly become excessively concerned with suicide and may even do it."
Dr Healy's analysis submitted to the FDA included the data from the pediatric trials on suicidality and hostility, including some that were concealed for years. To distinguish the difference between suicide caused by SSRI's verses suicide caused by the underlying depression, he separated the data on children who were treated for depression and children who were treated for obsessive compulsive disorder or social phobia.
The analysis found that SSRI's can cause some children who are not depressed to become suicidal when taking the drugs for other conditions. From a pool of 931 depressed patients taking SSRI's versus 811 depressed patients taking placebo, Dr Healy determined that there were 52 suicidal acts by patients on SSRI's versus 18 in the placebo group.
In a pool of 638 patients taking SSRI's for other disorders versus 562 patients taking a placebo, there were 10 suicidal acts in the SSRI group versus 1 in the placebo group.
When these data sets were combined, there were 62 episodes of suicidality in the 1,569 patients on SSRI's versus only 19 episodes in the 1,373 patients on a placebo.
In his submission to the FDA, Dr Healy also explained that he had conducted his own trial on Zoloft in 2000 with 20 "healthy volunteers," meaning they had no mental disorder when entering the trial, and two of the Zoloft patients became suicidal. This type of study provides the strongest evidence of drug-induced suicidality because it's impossible for drug companies to claim that a patient became suicidal as a result of the underlying depression.
Seven years ago, during the Wyoming jury trial involving the tragic Paxil-induced murder-suicide, the man's physician testified that he may not have prescribed Paxil if a warning regarding homicide and suicide had been added to the drug's label.
In his report released last month, Dr Glenmullen offers the following heart-wrenching conclusion to the court: "It is my opinion to a reasonable degree of medical probability that if GlaxoSmithKline had provided a warning all these years, Benjamin Bratt would still be alive today."
On April 24, 2004, the Lancet medical journal published an editorial entitled, "Depressing Research," with the following comments that surely ring doubly true today for the Bratt family, as well as all the other families whose children committed suicide while on SSRI's:
"It is hard to imagine the anguish experienced by the parents, relatives, and friends of a child who has taken his or her own life. That such an event could be precipitated by a supposedly beneficial drug is a catastrophe. The idea of that drug's use being based on the selective reporting of favourable research should be unimaginable."
Showing posts with label Study 329. Show all posts
Showing posts with label Study 329. Show all posts
Sunday, August 8, 2010
Lawmakers Catch Glaxo Hiding Paxil Suicide Risks - Again (Part II)
Evelyn Pringle February 13, 2008
Apparently, GlaxoSmithKline is still trying to hide damaging information about Paxil, because 9 pages of a report released from under a court order last month, are not available to the public. However, Senator Charles Grassley has instructed Glaxo to provide him with the full report by February 14, 2008.
In the report, which is dated roughly 6 months ago on June 29, 2007, Harvard Professor, Dr Joseph Glenmullen reveals that Glaxo had clinical trial data since 1989 which showed that Paxil increases the risk of suicide by more than 8-fold compared to patients who received a placebo.
The report was submitted in O'Neal v Glaxo, a lawsuit filed in a California federal court by the surviving family members of Benjamin Bratt who committed suicide at age 13 while on Paxil. The family is represented by the California law firm of Baum, Hedlund, Aristei & Goldman.
On January 30, 2008, the judge dismissed the case on the basis of the new preemption policy of the Bush Administration, but the family intends to ask the court to reconsider the ruling, according to Baum Hedlund.
In his report, Dr Glenmullen also makes a plea for public disclosure of all information that remains sealed under court orders on the basis of Glaxo's claim that the documents contain trade secrets and states:
"Given the importance of GlaxoSmithKline's internal documents, it is unfortunate that so many of the documents cited in this report and the attached Appendix are still confidential."
"Given the stakes for public health and safety, GlaxoSmithKline should not be permitted to claim the documents are proprietary trade secrets."
"All the documents should be made part of the public record so the full story of Paxil-induced suicidality can be told and the additional necessary steps can be taken to fully protect patients and the public."
Dr Glenmullen also mentions a companion report related to children and adolescents and a "Specific Causation Report" in the case of Benjamin Bratt, and Senator Grassley has instructed Glaxo to provide him with a copy of that report as well.
In what can only be viewed as an eerily prophetic comment, in a letter back on September 16, 2004, to the Secretary of Health and Human Services, and the acting FDA Commissioner at the time, Senator Grassley warned: "I intend to keep the FDA's feet to the fire to insure that the American public is knowledgeable about the risks of SSRI's."
SSRI's refer to antidepressants known as selective serotonin reuptake inhibitors that include Paxil, Eli Lilly's Prozac, Zoloft by Pfizer and Celexa and Lexapro marketed by Forest Labs, along with their generic counterparts. Lilly's Cymbalta, Wyeth's Effexor and Glaxo's Wellbutrin are often referred to as SSRI's but they are slightly different chemically. However, the new antidepressants all carry the same warnings about the suicide risks.
Senator Grassley's letter followed the vote by an FDA advisory committee for a black box warning about the increased risk of suicide with kids to be added to the drugs' labels.
His angry tone, and not so subtle threat, was due to the fact that, during the advisory committee meeting, it became apparent that not only Glaxo, but all the SSRI makers, had concealed and misrepresented clinical trial data for years in the published medical literature which clearly indicated that there was an increased risk of suicidality with SSRI use.
In fact, as soon as Glaxo's was asked about the hidden studies by regulators in the UK, Glaxo issued a "Dear Doctor" letter to physicians in England saying Paxil should not be prescribed to children because it "failed" to work any better than a placebo and frequently caused "hostility, agitation, emotional lability (including crying, mood fluctuations, self-harm, suicidal thoughts, and attempted suicides.)"
Glaxo did not issue any such warning to doctors in the US.
The paper that garnered the most wrath from pharmacology experts all over the world was published in the July 2001 issue of the Journal of the American Academy of Child and Adolescent Psychiatry on Paxil study 329, which was conducted from 1993 through to late 1995 or early 1996, according to a leading pharmacology expert, Dr David Healy.
Twenty academics, considered to be the tops in their field, signed off on the study. The main authors of paper on the study were later found to be in constant contact with Glaxo when the media began reporting that the data published was fraudulent, and include Dr Martin Keller, Dr Neil Ryan and Dr Karen Wagner.
In the paper, the authors write: "Of the 11 patients only headache (one patient) was considered to be related to the treatment," and Paxil is "generally well tolerated and effective."
However, when the actual study was analyzed in 2003, it showed suicidal acts by 5 out of 93 children on Paxil compared to no suicidal acts in the 89 children who received placebo.
On January 29, 2007, the BBC's Panorama broadcast, "Secrets of the Drug Trials." Attorney Karen Barth Menzies obtained many of the secret Paxil documents that were quoted during litigation, and she explained how Glaxo found ways "to blow up out of proportion the supposed benefits in Study 329 and downplayed the negative findings."
Glaxo recruited the opinion leaders to put their names on the published 329 study, she said, because they were academics whom everybody looked up to, and the company knew that doctors would be far more likely to prescribe Paxil after listening to these doctors than they would be if approached by Glaxo salespersons.
One letter that was quoted, revealed that these so-called opinion leaders never even wrote a paper. The letter was from a ghost writer to Dr Keller, informing him that all the necessary materials were enclosed for him to submit the study to a journal for publication. The packet even included a cover letter, with instructions telling Dr Keller to: "please re-type on your letterhead. Revise if you wish."
Dr Wagner, along with Dr Graham Emslie, was also responsible for publishing papers on studies that resulted in Prozac's approval for children, and Dr Wagner and Dr Keller were also investigators on Zoloft studies and several of the unpublished Paxil studies.
In the October 4, 1999 Boston Globe, Alison Bass reported that in 1998, as a professor at Brown University, Dr Keller was forced to forfeit "hundreds of thousands of dollars" in state grant money and was paid more than $500,000 in consulting fees in 1998, most of it from companies whose drugs he touted in medical journals and at conferences.
In the report, Ms Bass pointed out that Keller was a valuable resource for the University, and had brought in about $14.4 million in research funding from drug companies and federal agencies since 1993.
According to the report, in 1998, the year Keller published 3 studies with colleagues in the Journal of the American Medical Association and the Journal of Clinical Psychiatry touting the efficacy of Zoloft, he received $218,000 in personal income and more than $3 million in research funding from Zoloft maker Pfizer.
Several ethicists contacted by the Globe said Keller's unusually large consulting fees, a total of $556,000 in 1998 and $444,000 in 1997, constitute the most serious potential conflict they've heard of yet, Ms Bass noted.
Dr Wagner received an onslaught of criticism from experts all over the world when she misrepresented trial data in a paper on Zoloft, claiming it was safe and effective for use with children. On November 29, 2004, Barry Meier wrote, "Contracts Keep Drug Research Out of Reach," in the New York Times, and reported that over the past decade, Dr Wagner from the University of Texas Medical Center in Galveston had led or worked on some 20 studies published in medical journals and had also "attracted a large number of industry-financed studies, including those aimed at testing whether antidepressants approved for use in adults were safe and effective in children and adolescents."
In a financial filing with the university in December 1999, Mr Meier found the same month that a Zoloft trial began recruiting patients, Dr Wagner disclosed that she had received more than $10,000 from Pfizer but she did not provide details.
She also did not respond to written questions about the payments but a lawyer for the school, told Mr Meier that Dr Wagner had told him that Pfizer had paid her $20,500 during the course of the Zoloft trial.
Mr Meier also noted that academic researchers routinely receive speaking and consulting fees from companies whose products they test and at Galveston the financial threshold for such a review is $10,000. But the school lawyer, told Mr Meier that the center had been unable to locate records related to Pfizer's payments to Dr Wagner.
Glaxo's study 329 was successfully used to promote Paxil for children, and sales to kids skyrocketed to $55 million in 2002 alone. It also served as the smoking gun in a lawsuit filed against Glaxo by New York Attorney Elliot Spitzer, charging Glaxo with fraud for promoting the off-label use of Paxil to children while concealing and misrepresenting the data from 5 studies that showed the increased suicide risks and the fact that Paxil did not work with children. Glaxo settled out of court to shut that lawsuit down within 2 months.
In 2003, after reviewing the same fraudulent studies, the UK banned the use of Paxil with children, and the FDA scheduled an advisory committee meeting in February 2004 to review the data on all SSRI's.
In response to the announcements by the regulatory agencies, the American College of Neuropsychopharmacology (ACNP), which designated a Task Force in the early 1990's to review the SSRI trial data, and subsequently published an position paper saying SSRI's were not linked to suicide, appointed a new Task Force in September 2003, to study the matter again.
This Task Force was made up of many of the same authors whose published papers were under attack for being fraudulent and included Dr John Mann, Dr Graham Emslie, Dr Karen Wagner, Dr Neal Ryan, Dr Andrew Leon, Dr Fredrick Goodwin, Dr David Shaffer, Dr Beardslee, Dr Jan Fawcett, Dr Herbert Meltzer and Dr Ross Baldessarini.
Two weeks before the advisory committee meeting, the Task Force issued a report, once again claiming SSRI's did not cause suicide, and began making what many experts condemned as preemptive statements in the media to influence the advisory committee to vote against adding a warning about the risk of suicide to SSRI labels.
On January 21, 2007, WebMd's headline on the internet stated: "Group Finds No Suicide-Antidepressant Link".
"Our conclusion is that when you look at the SSRI's as a group, there is evidence they are effective for treating depression in children and adolescents," Dr Mann told WebMD.
"Instead of being a risk for suicidal behavior, they are potentially therapeutic," he stated.
In fact, the $30-million Dr Mann, who admitted under oath in a jury trial that it was possible that he got over $30 million in research funding from drug companies over a 10-year period, said the group found strong evidence that SSRI's help depressed kids and that suicide rates started going down when SSRI's became available.
He claimed that a 14-year study showed a decline in suicide rates in kids. "Across 15 countries there has been a 33% decline in suicide rates amongst youths," he told WebMD.
"Doctors must go on treating depression, and SSRI's appear to be a reasonable choice," he stated.
The FDA even allowed Task Force members Dr Andrew Leon and Dr Neil Ryan to participate as voting members of the February 2, 2004 advisory panel.
The day after a September 2004 advisory committee finally voted to add a black box warning to the SSRI labels, on September 14, 2004, Senator Grassley issued a press release stating that the FDA "needs to learn an important lesson from what's developed this year on the matter of kids and antidepressants."
"Transparency in government is the best policy," he noted. "Parents and doctors should not be left in the dark, and especially when information that's available could be a matter of life and death."
"Given the scientific findings," he added, "it's obvious that the strongest label warning for this class of drugs is critically important for the health and safety of young Americans."
"These measures are especially critical," he said, "since I also understand from previously released studies and from the Advisory Committee's own deliberations that only one of the nine antidepressant drugs has been proven to provide any benefit to children and adolescents."
"In fact," he pointed out, "in almost all cases, the FDA's own data demonstrates that these drugs actually perform no better than do placebos."
In a September 16, 2004, letter, Senator Grassley asked the FDA to "very quickly and fully consider" the recommendations for the black box and med guides, "before the lives of more children are needlessly lost because parents and others lack adequate, readily understandable information when they most need it."
He also brought up the issue of informed consent and said he was curious about the FDA's rationale for not requiring doctors to provide a clear, informed consent document that parents must read, understand and sign before accepting a prescription, as the FDA had done with the drug Lotronex, due to a 1 in 300 risk of ischemic colitis in patients.
In the case of antidepressants, Senator Grassley pointed out, "a suicide-related event involving Prozac (fluoxetine) is about 1 in 15 according to the TADS study, and about 1 in 30 for all SSRI's, according to FDA's own study."
The letter said that the informed consent form should at least include the following points: (1) Only Prozac has been shown to be effective in treating depression in children and adolescents, and is the only drug approved for this; (2) All others have been shown to be no different than a placebo, and their use in the treatment of children and adolescents is not an approved use; (3) All antidepressants increase the risk of suicidality, and (4) The risk of a suicide event (planned or actually attempted) is one for every 15 to 30 children and adolescents taking the antidepressant.
Senator Grassley also asked what the FDA planned to do about educating doctors and the public about the risk-benefits of antidepressants, especially in children. Obviously, the short answer to that question more than three years later is, not a thing.
In fact, in the January 17, 2008, Wall Street Journal, David Armstrong and Keith Winstein reported that, "the effectiveness of a dozen popular antidepressants has been exaggerated by selective publication of favorable results, according to a review of unpublished data submitted to the Food and Drug Administration."
"As a result," they wrote, "doctors and patients are getting a distorted view of how well blockbuster antidepressants like Wyeth's Effexor and Pfizer Inc.'s Zoloft really work," in discussing research led by Erick Turner, a psychiatrist at Oregon Health & Science University, published in a study in New England Journal of Medicine.
They also point out that sales of antidepressants total about $21 billion a year.
In all the studies, old and new, which promote the off-label sale of SSRI's for children with claims that the drugs work and do not cause suicide, almost without fail, the same names appear as investigators and authors. A complete listing includes Dr John Mann, Dr Martin Keller, Dr Graham Emslie, Dr Frederick Goodwin, Dr Karen Wagner, Dr Neal Ryan, Dr Charles Nemeroff, Dr David Dunner, Dr Andrew Leon, Dr John March, Dr David Shaffer, Dr John Rush, Dr Mark Olfson and Dr Robert Gibbons.
This time around, in addition to going after Glaxo for concealing and misrepresenting the data that showed an 8-fold increased risk of suicide, somebody needs to take the bull by the horns and see to it that these industry-funded quacks get thrown in the slammer.
It's also more than apparent that a few FDA officials belong there as well.
Apparently, GlaxoSmithKline is still trying to hide damaging information about Paxil, because 9 pages of a report released from under a court order last month, are not available to the public. However, Senator Charles Grassley has instructed Glaxo to provide him with the full report by February 14, 2008.
In the report, which is dated roughly 6 months ago on June 29, 2007, Harvard Professor, Dr Joseph Glenmullen reveals that Glaxo had clinical trial data since 1989 which showed that Paxil increases the risk of suicide by more than 8-fold compared to patients who received a placebo.
The report was submitted in O'Neal v Glaxo, a lawsuit filed in a California federal court by the surviving family members of Benjamin Bratt who committed suicide at age 13 while on Paxil. The family is represented by the California law firm of Baum, Hedlund, Aristei & Goldman.
On January 30, 2008, the judge dismissed the case on the basis of the new preemption policy of the Bush Administration, but the family intends to ask the court to reconsider the ruling, according to Baum Hedlund.
In his report, Dr Glenmullen also makes a plea for public disclosure of all information that remains sealed under court orders on the basis of Glaxo's claim that the documents contain trade secrets and states:
"Given the importance of GlaxoSmithKline's internal documents, it is unfortunate that so many of the documents cited in this report and the attached Appendix are still confidential."
"Given the stakes for public health and safety, GlaxoSmithKline should not be permitted to claim the documents are proprietary trade secrets."
"All the documents should be made part of the public record so the full story of Paxil-induced suicidality can be told and the additional necessary steps can be taken to fully protect patients and the public."
Dr Glenmullen also mentions a companion report related to children and adolescents and a "Specific Causation Report" in the case of Benjamin Bratt, and Senator Grassley has instructed Glaxo to provide him with a copy of that report as well.
In what can only be viewed as an eerily prophetic comment, in a letter back on September 16, 2004, to the Secretary of Health and Human Services, and the acting FDA Commissioner at the time, Senator Grassley warned: "I intend to keep the FDA's feet to the fire to insure that the American public is knowledgeable about the risks of SSRI's."
SSRI's refer to antidepressants known as selective serotonin reuptake inhibitors that include Paxil, Eli Lilly's Prozac, Zoloft by Pfizer and Celexa and Lexapro marketed by Forest Labs, along with their generic counterparts. Lilly's Cymbalta, Wyeth's Effexor and Glaxo's Wellbutrin are often referred to as SSRI's but they are slightly different chemically. However, the new antidepressants all carry the same warnings about the suicide risks.
Senator Grassley's letter followed the vote by an FDA advisory committee for a black box warning about the increased risk of suicide with kids to be added to the drugs' labels.
His angry tone, and not so subtle threat, was due to the fact that, during the advisory committee meeting, it became apparent that not only Glaxo, but all the SSRI makers, had concealed and misrepresented clinical trial data for years in the published medical literature which clearly indicated that there was an increased risk of suicidality with SSRI use.
In fact, as soon as Glaxo's was asked about the hidden studies by regulators in the UK, Glaxo issued a "Dear Doctor" letter to physicians in England saying Paxil should not be prescribed to children because it "failed" to work any better than a placebo and frequently caused "hostility, agitation, emotional lability (including crying, mood fluctuations, self-harm, suicidal thoughts, and attempted suicides.)"
Glaxo did not issue any such warning to doctors in the US.
The paper that garnered the most wrath from pharmacology experts all over the world was published in the July 2001 issue of the Journal of the American Academy of Child and Adolescent Psychiatry on Paxil study 329, which was conducted from 1993 through to late 1995 or early 1996, according to a leading pharmacology expert, Dr David Healy.
Twenty academics, considered to be the tops in their field, signed off on the study. The main authors of paper on the study were later found to be in constant contact with Glaxo when the media began reporting that the data published was fraudulent, and include Dr Martin Keller, Dr Neil Ryan and Dr Karen Wagner.
In the paper, the authors write: "Of the 11 patients only headache (one patient) was considered to be related to the treatment," and Paxil is "generally well tolerated and effective."
However, when the actual study was analyzed in 2003, it showed suicidal acts by 5 out of 93 children on Paxil compared to no suicidal acts in the 89 children who received placebo.
On January 29, 2007, the BBC's Panorama broadcast, "Secrets of the Drug Trials." Attorney Karen Barth Menzies obtained many of the secret Paxil documents that were quoted during litigation, and she explained how Glaxo found ways "to blow up out of proportion the supposed benefits in Study 329 and downplayed the negative findings."
Glaxo recruited the opinion leaders to put their names on the published 329 study, she said, because they were academics whom everybody looked up to, and the company knew that doctors would be far more likely to prescribe Paxil after listening to these doctors than they would be if approached by Glaxo salespersons.
One letter that was quoted, revealed that these so-called opinion leaders never even wrote a paper. The letter was from a ghost writer to Dr Keller, informing him that all the necessary materials were enclosed for him to submit the study to a journal for publication. The packet even included a cover letter, with instructions telling Dr Keller to: "please re-type on your letterhead. Revise if you wish."
Dr Wagner, along with Dr Graham Emslie, was also responsible for publishing papers on studies that resulted in Prozac's approval for children, and Dr Wagner and Dr Keller were also investigators on Zoloft studies and several of the unpublished Paxil studies.
In the October 4, 1999 Boston Globe, Alison Bass reported that in 1998, as a professor at Brown University, Dr Keller was forced to forfeit "hundreds of thousands of dollars" in state grant money and was paid more than $500,000 in consulting fees in 1998, most of it from companies whose drugs he touted in medical journals and at conferences.
In the report, Ms Bass pointed out that Keller was a valuable resource for the University, and had brought in about $14.4 million in research funding from drug companies and federal agencies since 1993.
According to the report, in 1998, the year Keller published 3 studies with colleagues in the Journal of the American Medical Association and the Journal of Clinical Psychiatry touting the efficacy of Zoloft, he received $218,000 in personal income and more than $3 million in research funding from Zoloft maker Pfizer.
Several ethicists contacted by the Globe said Keller's unusually large consulting fees, a total of $556,000 in 1998 and $444,000 in 1997, constitute the most serious potential conflict they've heard of yet, Ms Bass noted.
Dr Wagner received an onslaught of criticism from experts all over the world when she misrepresented trial data in a paper on Zoloft, claiming it was safe and effective for use with children. On November 29, 2004, Barry Meier wrote, "Contracts Keep Drug Research Out of Reach," in the New York Times, and reported that over the past decade, Dr Wagner from the University of Texas Medical Center in Galveston had led or worked on some 20 studies published in medical journals and had also "attracted a large number of industry-financed studies, including those aimed at testing whether antidepressants approved for use in adults were safe and effective in children and adolescents."
In a financial filing with the university in December 1999, Mr Meier found the same month that a Zoloft trial began recruiting patients, Dr Wagner disclosed that she had received more than $10,000 from Pfizer but she did not provide details.
She also did not respond to written questions about the payments but a lawyer for the school, told Mr Meier that Dr Wagner had told him that Pfizer had paid her $20,500 during the course of the Zoloft trial.
Mr Meier also noted that academic researchers routinely receive speaking and consulting fees from companies whose products they test and at Galveston the financial threshold for such a review is $10,000. But the school lawyer, told Mr Meier that the center had been unable to locate records related to Pfizer's payments to Dr Wagner.
Glaxo's study 329 was successfully used to promote Paxil for children, and sales to kids skyrocketed to $55 million in 2002 alone. It also served as the smoking gun in a lawsuit filed against Glaxo by New York Attorney Elliot Spitzer, charging Glaxo with fraud for promoting the off-label use of Paxil to children while concealing and misrepresenting the data from 5 studies that showed the increased suicide risks and the fact that Paxil did not work with children. Glaxo settled out of court to shut that lawsuit down within 2 months.
In 2003, after reviewing the same fraudulent studies, the UK banned the use of Paxil with children, and the FDA scheduled an advisory committee meeting in February 2004 to review the data on all SSRI's.
In response to the announcements by the regulatory agencies, the American College of Neuropsychopharmacology (ACNP), which designated a Task Force in the early 1990's to review the SSRI trial data, and subsequently published an position paper saying SSRI's were not linked to suicide, appointed a new Task Force in September 2003, to study the matter again.
This Task Force was made up of many of the same authors whose published papers were under attack for being fraudulent and included Dr John Mann, Dr Graham Emslie, Dr Karen Wagner, Dr Neal Ryan, Dr Andrew Leon, Dr Fredrick Goodwin, Dr David Shaffer, Dr Beardslee, Dr Jan Fawcett, Dr Herbert Meltzer and Dr Ross Baldessarini.
Two weeks before the advisory committee meeting, the Task Force issued a report, once again claiming SSRI's did not cause suicide, and began making what many experts condemned as preemptive statements in the media to influence the advisory committee to vote against adding a warning about the risk of suicide to SSRI labels.
On January 21, 2007, WebMd's headline on the internet stated: "Group Finds No Suicide-Antidepressant Link".
"Our conclusion is that when you look at the SSRI's as a group, there is evidence they are effective for treating depression in children and adolescents," Dr Mann told WebMD.
"Instead of being a risk for suicidal behavior, they are potentially therapeutic," he stated.
In fact, the $30-million Dr Mann, who admitted under oath in a jury trial that it was possible that he got over $30 million in research funding from drug companies over a 10-year period, said the group found strong evidence that SSRI's help depressed kids and that suicide rates started going down when SSRI's became available.
He claimed that a 14-year study showed a decline in suicide rates in kids. "Across 15 countries there has been a 33% decline in suicide rates amongst youths," he told WebMD.
"Doctors must go on treating depression, and SSRI's appear to be a reasonable choice," he stated.
The FDA even allowed Task Force members Dr Andrew Leon and Dr Neil Ryan to participate as voting members of the February 2, 2004 advisory panel.
The day after a September 2004 advisory committee finally voted to add a black box warning to the SSRI labels, on September 14, 2004, Senator Grassley issued a press release stating that the FDA "needs to learn an important lesson from what's developed this year on the matter of kids and antidepressants."
"Transparency in government is the best policy," he noted. "Parents and doctors should not be left in the dark, and especially when information that's available could be a matter of life and death."
"Given the scientific findings," he added, "it's obvious that the strongest label warning for this class of drugs is critically important for the health and safety of young Americans."
"These measures are especially critical," he said, "since I also understand from previously released studies and from the Advisory Committee's own deliberations that only one of the nine antidepressant drugs has been proven to provide any benefit to children and adolescents."
"In fact," he pointed out, "in almost all cases, the FDA's own data demonstrates that these drugs actually perform no better than do placebos."
In a September 16, 2004, letter, Senator Grassley asked the FDA to "very quickly and fully consider" the recommendations for the black box and med guides, "before the lives of more children are needlessly lost because parents and others lack adequate, readily understandable information when they most need it."
He also brought up the issue of informed consent and said he was curious about the FDA's rationale for not requiring doctors to provide a clear, informed consent document that parents must read, understand and sign before accepting a prescription, as the FDA had done with the drug Lotronex, due to a 1 in 300 risk of ischemic colitis in patients.
In the case of antidepressants, Senator Grassley pointed out, "a suicide-related event involving Prozac (fluoxetine) is about 1 in 15 according to the TADS study, and about 1 in 30 for all SSRI's, according to FDA's own study."
The letter said that the informed consent form should at least include the following points: (1) Only Prozac has been shown to be effective in treating depression in children and adolescents, and is the only drug approved for this; (2) All others have been shown to be no different than a placebo, and their use in the treatment of children and adolescents is not an approved use; (3) All antidepressants increase the risk of suicidality, and (4) The risk of a suicide event (planned or actually attempted) is one for every 15 to 30 children and adolescents taking the antidepressant.
Senator Grassley also asked what the FDA planned to do about educating doctors and the public about the risk-benefits of antidepressants, especially in children. Obviously, the short answer to that question more than three years later is, not a thing.
In fact, in the January 17, 2008, Wall Street Journal, David Armstrong and Keith Winstein reported that, "the effectiveness of a dozen popular antidepressants has been exaggerated by selective publication of favorable results, according to a review of unpublished data submitted to the Food and Drug Administration."
"As a result," they wrote, "doctors and patients are getting a distorted view of how well blockbuster antidepressants like Wyeth's Effexor and Pfizer Inc.'s Zoloft really work," in discussing research led by Erick Turner, a psychiatrist at Oregon Health & Science University, published in a study in New England Journal of Medicine.
They also point out that sales of antidepressants total about $21 billion a year.
In all the studies, old and new, which promote the off-label sale of SSRI's for children with claims that the drugs work and do not cause suicide, almost without fail, the same names appear as investigators and authors. A complete listing includes Dr John Mann, Dr Martin Keller, Dr Graham Emslie, Dr Frederick Goodwin, Dr Karen Wagner, Dr Neal Ryan, Dr Charles Nemeroff, Dr David Dunner, Dr Andrew Leon, Dr John March, Dr David Shaffer, Dr John Rush, Dr Mark Olfson and Dr Robert Gibbons.
This time around, in addition to going after Glaxo for concealing and misrepresenting the data that showed an 8-fold increased risk of suicide, somebody needs to take the bull by the horns and see to it that these industry-funded quacks get thrown in the slammer.
It's also more than apparent that a few FDA officials belong there as well.
Saturday, August 7, 2010
GlaxoSmithKline Defamed With Truth About Paxil
Evelyn Pringle January 31, 2007
GlaxoSmithKline has labeled the allegations made in a Panorama television program that said the company had suppressed the results of clinical trials that showed Paxil was ineffective and caused children to become suicidal "defamatory."
According to the January 30, 2007, Guardian, an official at the company said Glaxo had looked into taking legal action, "but that there wouldn't be much to gain from taking action against the BBC".
The Guardian also reported that Glaxo "utterly rejects any suggestion that it has improperly withheld drug trial information."
This is not news. Glaxo has falsely denied these assertions probably 100 times in the past from one end of the globe to the other. If Glaxo files a lawsuit against the BBC, it might as well file a worldwide class action against all the other "defamers" who for some reason or another repeated the exact same allegations.
The BBC has broadcast several Panorama programs on Glaxo's marketing of Paxil for children even after the company's own research showed the drug to be ineffective and dangerous with children. The latest program titled, "Secrets of the Drug Trials," was broadcast on January 29, 2007.
Glaxo's worn-out declarations of innocence can only be adequately responded to by highlighting a few of the historical moments in Paxil's never-ending trail of misery.
A good place to start is Wyoming in the year 2000, with the trial involving the case of Donald Schell, who had been on Paxil just two days when he killed his wife, daughter and infant granddaughter before killing himself.
His surviving son-in-law, Tim Tobin, brought a wrongful death lawsuit against Glaxo.
Prior to the trial, an expert for the plaintiff, Dr David Healy, a well-recognized expert on selective seratonin reuptake inhibitor antidepressants (SSRIs), was given access to Glaxo's files on the Paxil studies.
He spent two days reviewing several hundred thousand documents looking for reports on the trials conducted on "healthy volunteers." Healthy volunteer refers to study participants who were not depressed or mentally ill to begin with before taking a drug. If it was shown that suicidality was evident in health volunteers it would disprove Glaxo's theory that suicide was caused by the underlying illness of depression.
Dr Healy was interested in these trials because he knew of recent studies that had surfaced on another SSRI, Pfizer's Zoloft, that showed the drugs could trigger suicidality in healthy volunteers. When he finally found the right files, Dr Healy told the BBC:
"It seemed clear that some people that went on the drugs had no major problems, but equally clear that others who went on the drug ended up more restless, in a state of mental turmoil, complaining about dreams, nightmares and a range of things like this. These don't seem to have been explored further in any great detail."
Dr Healy discovered that one in 4 healthy volunteers suffered this mental turmoil even when they were on normal doses of Paxil and had only been taking it for a few days.
In addition, he found the agitation was worse when the dose was increased and cleared up when Paxil was stopped, only to reemerge when it was started again. There had also been a suicide in the program, and in one healthy volunteer study, Paxil was linked to withdrawal effects in around 85% of subjects.
After hearing the testimony of Dr Healy, the Wyoming jury awarded Mr Tobin more than $6 million in damages in the first jury verdict against a drug maker for the psychiatric side effects caused by an SSRI.
Going up against SSRI makers on behalf of SSRI victims has cost Dr Healy plenty. In 2000, he accepted a position at the University of Toronto, but in the wake of a lecture at the University in November 2000, in which he mentioned that there had been an almost complete lack of research on the risk of suicide associated with SSRIs, Dr Healy was informed that he had lost his job before it even began.
The next historical moment worth noting in the Paxil saga took place in June 2004, when New York's attorney general, Elliot Spitzer, filed charges of consumer fraud against Glaxo and alleged that the company had "repeatedly" concealed damaging information in Paxil studies conducted on children.
The complaint stated that, "starting in 1998, GSK engaged in a concerted effort to withhold negative information concerning Paxil and misrepresented data concerning Paxil's safety and efficacy when prescribed for depression in children and adolescents."
It also alleged an internal 1999, document showed that the company intended to "manage the dissemination of data in order to minimize any potential negative commercial impact.''
The lawsuit charged that Glaxo conducted at least 5 studies on Paxil with children, but only published one. A study referred to as Study 377, noted that some children exhibited suicidal behaviors and attempts to commit suicide. Referring to that study, and also Study 329, the complaint alleged, an internal Glaxo memo acknowledged that Paxil "failed to demonstrate a statistically significant difference from placebo on the primary efficacy measures."
Glaxo might want to add Mr Spitzer as a defendant in the worldwide class action for his "defamatory" remarks, made in print no less. According to a June 2, 2004, press release by Mr Spitzer, by concealing negative studies, Glaxo made out like a bandit in 2002, with more than 2 million pediatric prescriptions for Paxil written in the US. "Prescriptions for Paxil to treat mood disorders in children and adolescents," Mr Spitzer said, "translated into US sales for GSK of approximately $55 million in 2002 alone."
The lawsuit also alleged that Glaxo misrepresented the results of the company's own research to its sales representatives who promoted Paxil to physicians and portrayed the drug as having "remarkable efficacy and safety in the treatment of adolescent depression," when in fact, the studies did not demonstrate that Paxil was effective in treating children and showed the possibility of increased risk of suicidal thoughts and acts in adolescents.
The suit further alleged that Glaxo failed to disclose this information in "Medical Information Letters" that it sent to physicians, and thus deprived physicians of the information needed to evaluate the risks and benefits of prescribing Paxil for children and deprived children of the benefit of their doctor's professional judgment.
In August 2004, to settle the charges that were based on the same allegations made during the Panorama program that Glaxo now claims are "defamatory," Glaxo agreed to pay $2.5 million and to publicly disclose all clinical studies.
Glaxo's largest clinical trial on the use of Paxil with children was conducted in the US in the 1990s, and was called Study 329. Child psychiatrist, Dr Neal Ryan, of the University of Pittsburgh, was paid by Glaxo and was listed as co-author of the study.
In 2002, Dr Ryan also gave a talk on childhood depression at a medical conference sponsored by Glaxo and said that Paxil would be a suitable treatment for children. He later told Panorama reporter, Shelley Jofre, that Paxil had probably lowered rather than raised suicide rates.
But an internal company email penned by a public relations executive working for Glaxo describes Study 329 differently. "Originally we had planned to do extensive media relations surrounding this study," it said, "until we actually viewed the results."
"Essentially the study did not really show it was effective in treating adolescent depression," the email stated, "which is not something we want to publicise."
However, the manipulated results from Study 329 were in fact published in the Journal of American Child Adolescent Psychiatry in 2001, with the positive spin stating, "Paxil is generally well tolerated and effective for major depression in adolescents."
Another publication that Glaxo might want to add as a defendant in its class action against the world would be the Canadian Medical Association Journal. In March 2004, the Journal printed excerpts from an internal Glaxo memo to illustrate how the company had withheld studies from regulatory agencies that showed the ineffectiveness of Paxil with children which stated in part: "It would be unacceptable to include a statement that efficacy had not been demonstrated, as this would undermine the profile of paroxetine".
A television program in the US could be added to the list of "defamers" as well. Back in December 2004, ABC's "Primetime Live," also said it had obtained hidden Glaxo studies and reported that some children in the studies showed the same types of suicidal thoughts and behaviors that parents had for years claimed their children were exhibiting.
According to these documents, Primetime said, internal studies showed Paxil had little or no effect in treating depression in children and adolescents and as far back as 1997, the company was aware of suicide related behaviors in young patients taking the drug.
In spite of this information, Primetime reported, Glaxo distributed a memo to its sales force in 2001 touting the drug's "remarkable efficacy and safety in the treatment of adolescent depression."
And last but not least, another "defamer" would appear to be the US Congress. It too claimed that Glaxo hid negative studies in the name of profits. "This is about money," said Representative, Henry Waxman (D-CA), who was on a congressional committee investigating SSRI makers at the time.
"This is not about science," he stated, "because what they're doing is withholding the scientific information, suppressing the studies that could have a negative impact on their sales and their profits."
GlaxoSmithKline has labeled the allegations made in a Panorama television program that said the company had suppressed the results of clinical trials that showed Paxil was ineffective and caused children to become suicidal "defamatory."
According to the January 30, 2007, Guardian, an official at the company said Glaxo had looked into taking legal action, "but that there wouldn't be much to gain from taking action against the BBC".
The Guardian also reported that Glaxo "utterly rejects any suggestion that it has improperly withheld drug trial information."
This is not news. Glaxo has falsely denied these assertions probably 100 times in the past from one end of the globe to the other. If Glaxo files a lawsuit against the BBC, it might as well file a worldwide class action against all the other "defamers" who for some reason or another repeated the exact same allegations.
The BBC has broadcast several Panorama programs on Glaxo's marketing of Paxil for children even after the company's own research showed the drug to be ineffective and dangerous with children. The latest program titled, "Secrets of the Drug Trials," was broadcast on January 29, 2007.
Glaxo's worn-out declarations of innocence can only be adequately responded to by highlighting a few of the historical moments in Paxil's never-ending trail of misery.
A good place to start is Wyoming in the year 2000, with the trial involving the case of Donald Schell, who had been on Paxil just two days when he killed his wife, daughter and infant granddaughter before killing himself.
His surviving son-in-law, Tim Tobin, brought a wrongful death lawsuit against Glaxo.
Prior to the trial, an expert for the plaintiff, Dr David Healy, a well-recognized expert on selective seratonin reuptake inhibitor antidepressants (SSRIs), was given access to Glaxo's files on the Paxil studies.
He spent two days reviewing several hundred thousand documents looking for reports on the trials conducted on "healthy volunteers." Healthy volunteer refers to study participants who were not depressed or mentally ill to begin with before taking a drug. If it was shown that suicidality was evident in health volunteers it would disprove Glaxo's theory that suicide was caused by the underlying illness of depression.
Dr Healy was interested in these trials because he knew of recent studies that had surfaced on another SSRI, Pfizer's Zoloft, that showed the drugs could trigger suicidality in healthy volunteers. When he finally found the right files, Dr Healy told the BBC:
"It seemed clear that some people that went on the drugs had no major problems, but equally clear that others who went on the drug ended up more restless, in a state of mental turmoil, complaining about dreams, nightmares and a range of things like this. These don't seem to have been explored further in any great detail."
Dr Healy discovered that one in 4 healthy volunteers suffered this mental turmoil even when they were on normal doses of Paxil and had only been taking it for a few days.
In addition, he found the agitation was worse when the dose was increased and cleared up when Paxil was stopped, only to reemerge when it was started again. There had also been a suicide in the program, and in one healthy volunteer study, Paxil was linked to withdrawal effects in around 85% of subjects.
After hearing the testimony of Dr Healy, the Wyoming jury awarded Mr Tobin more than $6 million in damages in the first jury verdict against a drug maker for the psychiatric side effects caused by an SSRI.
Going up against SSRI makers on behalf of SSRI victims has cost Dr Healy plenty. In 2000, he accepted a position at the University of Toronto, but in the wake of a lecture at the University in November 2000, in which he mentioned that there had been an almost complete lack of research on the risk of suicide associated with SSRIs, Dr Healy was informed that he had lost his job before it even began.
The next historical moment worth noting in the Paxil saga took place in June 2004, when New York's attorney general, Elliot Spitzer, filed charges of consumer fraud against Glaxo and alleged that the company had "repeatedly" concealed damaging information in Paxil studies conducted on children.
The complaint stated that, "starting in 1998, GSK engaged in a concerted effort to withhold negative information concerning Paxil and misrepresented data concerning Paxil's safety and efficacy when prescribed for depression in children and adolescents."
It also alleged an internal 1999, document showed that the company intended to "manage the dissemination of data in order to minimize any potential negative commercial impact.''
The lawsuit charged that Glaxo conducted at least 5 studies on Paxil with children, but only published one. A study referred to as Study 377, noted that some children exhibited suicidal behaviors and attempts to commit suicide. Referring to that study, and also Study 329, the complaint alleged, an internal Glaxo memo acknowledged that Paxil "failed to demonstrate a statistically significant difference from placebo on the primary efficacy measures."
Glaxo might want to add Mr Spitzer as a defendant in the worldwide class action for his "defamatory" remarks, made in print no less. According to a June 2, 2004, press release by Mr Spitzer, by concealing negative studies, Glaxo made out like a bandit in 2002, with more than 2 million pediatric prescriptions for Paxil written in the US. "Prescriptions for Paxil to treat mood disorders in children and adolescents," Mr Spitzer said, "translated into US sales for GSK of approximately $55 million in 2002 alone."
The lawsuit also alleged that Glaxo misrepresented the results of the company's own research to its sales representatives who promoted Paxil to physicians and portrayed the drug as having "remarkable efficacy and safety in the treatment of adolescent depression," when in fact, the studies did not demonstrate that Paxil was effective in treating children and showed the possibility of increased risk of suicidal thoughts and acts in adolescents.
The suit further alleged that Glaxo failed to disclose this information in "Medical Information Letters" that it sent to physicians, and thus deprived physicians of the information needed to evaluate the risks and benefits of prescribing Paxil for children and deprived children of the benefit of their doctor's professional judgment.
In August 2004, to settle the charges that were based on the same allegations made during the Panorama program that Glaxo now claims are "defamatory," Glaxo agreed to pay $2.5 million and to publicly disclose all clinical studies.
Glaxo's largest clinical trial on the use of Paxil with children was conducted in the US in the 1990s, and was called Study 329. Child psychiatrist, Dr Neal Ryan, of the University of Pittsburgh, was paid by Glaxo and was listed as co-author of the study.
In 2002, Dr Ryan also gave a talk on childhood depression at a medical conference sponsored by Glaxo and said that Paxil would be a suitable treatment for children. He later told Panorama reporter, Shelley Jofre, that Paxil had probably lowered rather than raised suicide rates.
But an internal company email penned by a public relations executive working for Glaxo describes Study 329 differently. "Originally we had planned to do extensive media relations surrounding this study," it said, "until we actually viewed the results."
"Essentially the study did not really show it was effective in treating adolescent depression," the email stated, "which is not something we want to publicise."
However, the manipulated results from Study 329 were in fact published in the Journal of American Child Adolescent Psychiatry in 2001, with the positive spin stating, "Paxil is generally well tolerated and effective for major depression in adolescents."
Another publication that Glaxo might want to add as a defendant in its class action against the world would be the Canadian Medical Association Journal. In March 2004, the Journal printed excerpts from an internal Glaxo memo to illustrate how the company had withheld studies from regulatory agencies that showed the ineffectiveness of Paxil with children which stated in part: "It would be unacceptable to include a statement that efficacy had not been demonstrated, as this would undermine the profile of paroxetine".
A television program in the US could be added to the list of "defamers" as well. Back in December 2004, ABC's "Primetime Live," also said it had obtained hidden Glaxo studies and reported that some children in the studies showed the same types of suicidal thoughts and behaviors that parents had for years claimed their children were exhibiting.
According to these documents, Primetime said, internal studies showed Paxil had little or no effect in treating depression in children and adolescents and as far back as 1997, the company was aware of suicide related behaviors in young patients taking the drug.
In spite of this information, Primetime reported, Glaxo distributed a memo to its sales force in 2001 touting the drug's "remarkable efficacy and safety in the treatment of adolescent depression."
And last but not least, another "defamer" would appear to be the US Congress. It too claimed that Glaxo hid negative studies in the name of profits. "This is about money," said Representative, Henry Waxman (D-CA), who was on a congressional committee investigating SSRI makers at the time.
"This is not about science," he stated, "because what they're doing is withholding the scientific information, suppressing the studies that could have a negative impact on their sales and their profits."
Weighing Benefits of SSRIs Against Suicide Risk
Evelyn Pringle December 8, 2006
Before the FDA's Psychopharmacologic Drugs Advisory Committee begins the discussion at the December 13, 2006, public hearing on the suicide risks associated with selective serotonin inhibitor antidepressants, it should get honest with the audience and openly admit that the SSRIs do not even work.
Medical professionals maintain that in order to justify the use of a drug, its benefits are supposed to outweigh its risks and therefore, there should be a discussion of exactly what benefits result from the use of SSRIs, in any population, that would outweigh the suicide risks associated with this class of medications.
The most popular SSRIs sold in the US include Paxil, Prozac, Zoloft, Lexapro and Celexa.
As far as the benefits of the various SSRIs, an April 2002 study in the Journal of American Medical Association compared the effectiveness of Zoloft, St John's Wort, and a placebo and found that the placebo treated patients had the highest rate of remission of symptoms at 31.9%, and Zoloft's 24.8% was barely better than the rate of remission with St John's Wort of 23.9%.
The FDA's own records on Celexa (citalopram) show the agency knew the drug to be ineffective when it was approved, and the agency based its approval on 2 marginally positive studies out of a total of 17 conducted.
A March 26, 1998, memorandum by Thomas Laughren, of the FDA's Psychiatric Drug Products, notes a total of 17 clinical trials on Celexa, including 2 uncontrolled trials, 6 active controlled trials showing no difference between treatments, and 2 placebo controlled trials that were too small to be considered studies.
Dr Laughren's memo discusses 5 short-term trials (85A, 91206, 86141, 89303, and 89306) and 2 long-term studies (89304 and 89305). "In summary," he wrote, "I consider studies 85A and 91206 positive support for the claim of short-term antidepressant efficacy for citalopram."
"While 3 other placebo-controlled short-term trials (86141, 89303, and 89306) were negative, and not easily interpretable since there were no active control arms," he stated, "I feel there were sufficient reasons to speculate about the negative outcomes and, therefore, not count these studies against citalopram."
Dr Laughman also counted 2 relapse prevention trials as effective to support the drug's approval. "Overall," he wrote, "I consider these results sufficient to support claims of both short-term and long-term antidepressant effectiveness of citalopram."
However, other FDA officials were not so eager to stretch the truth about the weak studies with medical professionals and consumers. For instance, a May 4, 1998 memo by Paul Leber, Director of the Division of Neuropharmacological Drug Projects, on the subject of "Approvable Action on Forrest Laboratories NDA 20-822 Celexa," said the pubic had a right to know the truth about all the trials submitted to the FDA for the approval of Celexa.
He advised that the drug labeling should not only describe the trials that showed Celexa's adequate effects; but should also describe the "well controlled clinical studies that failed to do so."
Dr Leber specifically pointed out that Study 86141, Study 89303, and Study 89306, all failed to provide results confirming the positive findings of Studies 85 and 91206, the two clinical trials that Dr Laughman listed to support the approval of Celexa.
"I am aware that clinical studies often fail to document the efficacy of effective drugs," Dr Leber wrote, "but I doubt the public, or even the majority of medical community, are aware of this fact," he said.
"I believe that labeling," he stated, "that selectively describes positive studies and excludes mention of negative ones can be viewed as being potentially "false and misleading.""
"I believe it is useful for the prescriber, patient, and 3rd party payer to know," Dr Leber wrote, "without having to gain access to official FDA review documents, that citalopram's antidepressants effects were not detected in every controlled clinical trial intended to demonstrate those effects."
"I am persuaded," he stated, "they not only have a right to know, but should know."
When Forest Labs got Lexapro approved in 2002, it was nothing more than a chemically altered version of Celexa, and Forest Labs spent a fortune on persuading doctors to switch patients to Lexapro before its top selling drug Celexa lost its patent protection in 2004.
At the time, Forest could point to only one lone study, that the company itself paid to have published that claimed Lexapro was any better than Celexa. The paper, by Dr Jack Gorman, of the Mount Sinai School of Medicine, pooled the results of three studies and concluded that Lexapro "may have a faster onset" than Celexa, according to a report by Melody Peterson in the November 22, 2002 New York Times.
Dr Gorman's paper was published in CNS Spectrums, a medical journal he edits, and Forest paid Medworks Media, a small medical marketing company that publishes the journal, to print the article in a special supplement.
Other researchers disagreed with the study results. "The Medical Letter, a nonprofit newsletter respected for its independence from the pharmaceutical industry," Ms Petersen reports, "reviewed the same clinical trials as Dr. Gorman and concluded ... that Lexapro had not been shown to be better than any other antidepressant, including Celexa."
As for Paxil, in June 2004, New York State Attorney General, Eliot Spitzer, charged GlaxoSmithKline, with fraud for hiding studies that "not only failed to show any benefit for the drug in children but demonstrated that children taking Paxil were more likely to become suicidal than those taking a placebo."
According to Mr Spitzer, Glaxo published only one of 5 studies it conducted, and even that one showed mixed results.
Prozac (fluoxetine) was also known to be ineffective before it was approved for use in the US. While serving as an expert witness in a lawsuit, psychiatrist and SSRI expert, Dr Peter Breggin, author of, "Talking Back to Prozac," reviewed a July 1985 in-house analysis by its maker, Eli Lilly, that showed Prozac had failed to demonstrate efficacy in clinical trials with patients taking Prozac verses a placebo or a tricyclic antidepressant.
"When this potential economic disaster for Eli Lilly was discovered," Dr Beggin reports, "the FDA allowed the company to include in its efficacy data those patients who had been illegally treated with concomitant benzodiazepine tranquilizers in order to calm their over stimulation."
"Basically, Prozac was approved in combination with addictive benzodiazepines such as Ativan, Xanax, and Valium," he says, "but neither the FDA nor the drug company revealed this information."
"With these patients included," he states, "statistical manipulations enabled the FDA to find the drug marginally approvable."
An internal Lilly document dated March 29, 1985, says, "The benefits vs. risks considerations for fluoxetine currently does not fall clearly in favor of the benefits."
Medwatch is the reporting system by which adverse events involving prescription drugs are reported to the FDA. Within one decade of Prozac's arrival on the market, there were 39,000 adverse event reports submitted to Medwatch and that number is said to represent only about 1% of the actual number of adverse events, according to an April 22, 2006 report by the Citizens Commission on Human Rights.
Serious questions about the possible link between suicide and SSRIs began in 1990, when Martin Teicher, of McLean Hospital in Massachusetts, reported on 6 patients who he said experienced "intense, violent suicidal thoughts" after taking Prozac.
He offered three possible theories for the increased suicidality: (1) SSRIs gave patients more energy before lifting their depression, allowing them to act on a suicidal impulse; (2) the drugs worsened depression in a small subset of patients; or (3) SSRIs caused a state of agitation and restlessness.
In a February 10, 1990, report titled, "Emergence of Intense Suicidal Preoccupation During Fluoxetine Treatment," Dr Teicher said, "The purpose of this report is to suggest the surprising possibility that fluoxetine may induce suicidal ideation in some patients."
"In our experience," he wrote, "this side effect has occurred in 3.5% of patients receiving fluoxetine."
Throughout the 1990s, Eli Lilly publicly denied that Prozac was associated with suicide or violence, but by the year 2000, the company had quietly paid an estimated $50 million to settle over 30 lawsuits, according to an Indianapolis Star investigation.
When reviewing Lilly's studies on Prozac, Dr Breggin found that there were 12 suicide attempts in the Prozac group verses only one in the placebo group and one in the tricyclic antidepressant group, but that many of the suicide attempts were hidden under false categories.
"Even after the company winnowed out six of the suicide attempts," Dr Breggin says, "the remaining 6:1 ratio was alarming."
He also reviewed a November 8, 1998, study titled, "Activation and Sedation in Fluoxetine Clinical Trials," that showed a 38% rate of stimulation in the patients taking Prozac, even though, he says, many patients were sedated and many parameters of stimulation were not counted.
Another group of documents that he examined, contained a study conducted by the FDA on increased spontaneous post marketing reports of "hostility" and "intentional injury" by patients on Prozac. "These documents," Dr Breggin says, "were generated shortly before the 1991 FDA PDAC meeting that evaluated antidepressant-induced suicidality."
For this study, the FDA used the antidepressant, trazodone, as a control and found a 24-fold relative increase of reports of hostility and intentional injury per prescription of Prozac when compared to patients on trazodone.
"The spike in Prozac reports," Dr Breggins says, "occurred even before any public controversy surrounding Prozac and violence."
The documents he reviewed also contained graphs showing a 40-fold relative increase in reports of suicide attempts, overdose, and psychotic depression, in patients on Prozac compared to patients on trazodone.
"In one memo," Dr Breggin reports, "a Lilly employee expresses shame and regret about hiding this data."
In the case where Dr Breggin testified, Lilly was able to have the records sealed by the court where they remained hidden for roughly 10 years.
On April 10, 2004, the British Medical Journal, citing Jurendi et al, criticized the authors of studies on SSRIs for exaggerating benefits and downplaying their harm and noted a clinical trial of 93 children on Paxil that produced 11 serious adverse events, including 7 hospitalizations, compared to only two in children in the placebo group.
But the Paxil suicide risk does not only apply to children. An August 22, 2005, study by Norwegian researchers found that Paxil also increases suicide risk in adults. In the study of over 1,500 adults, 7 Paxil patients attempted suicide compared to only one attempt in the group of patients on a placebo. The researchers recommended that the warning not to prescribe Paxil to children should be extended to adults.
In Insight News, on October 4, 2002, investigative reporter, Kelly Patricia O'Meara, author of, "Psyched Out, How Psychiatry Sells Mental Illness and Pushes Pills That Kill (2006)," revealed a study conducted by Dr Arif Khan, medical director of the Northwest Clinical Research Center in Bellevue, Washington, that disclosed the number of suicides committed or attempted by patients in the clinical trials on SSRIs, that were kept hidden from doctors and consumers.
For the study, Dr Khan examined the official clinical drug-trial data for all SSRIs approved by the FDA between 1985 and 2000.
According to Ms O'Meara, the rate of suicides in the general public is 11 in 100,000, but the incidence rate for people participating in the SSRI trials was 718 for every 100,000. Dr Kahn's research also revealed that nearly 4% of study participants attempted suicide within the following year.
As for weighing the benefits against the above risks, the British Medical Journal published a study on July 16, 2005, by Joanna Moncrieff, senior lecturer in psychiatry at University College London, that found SSRIs no more effective than a placebo in reducing depression.
The study also found that trials on SSRIs with negative results were less likely to be published than those with positive results, and that even in the published trials, negative outcomes were often not presented.
Dr Moncrieff said she found "no good evidence that these drugs work."
Before the FDA's Psychopharmacologic Drugs Advisory Committee begins the discussion at the December 13, 2006, public hearing on the suicide risks associated with selective serotonin inhibitor antidepressants, it should get honest with the audience and openly admit that the SSRIs do not even work.
Medical professionals maintain that in order to justify the use of a drug, its benefits are supposed to outweigh its risks and therefore, there should be a discussion of exactly what benefits result from the use of SSRIs, in any population, that would outweigh the suicide risks associated with this class of medications.
The most popular SSRIs sold in the US include Paxil, Prozac, Zoloft, Lexapro and Celexa.
As far as the benefits of the various SSRIs, an April 2002 study in the Journal of American Medical Association compared the effectiveness of Zoloft, St John's Wort, and a placebo and found that the placebo treated patients had the highest rate of remission of symptoms at 31.9%, and Zoloft's 24.8% was barely better than the rate of remission with St John's Wort of 23.9%.
The FDA's own records on Celexa (citalopram) show the agency knew the drug to be ineffective when it was approved, and the agency based its approval on 2 marginally positive studies out of a total of 17 conducted.
A March 26, 1998, memorandum by Thomas Laughren, of the FDA's Psychiatric Drug Products, notes a total of 17 clinical trials on Celexa, including 2 uncontrolled trials, 6 active controlled trials showing no difference between treatments, and 2 placebo controlled trials that were too small to be considered studies.
Dr Laughren's memo discusses 5 short-term trials (85A, 91206, 86141, 89303, and 89306) and 2 long-term studies (89304 and 89305). "In summary," he wrote, "I consider studies 85A and 91206 positive support for the claim of short-term antidepressant efficacy for citalopram."
"While 3 other placebo-controlled short-term trials (86141, 89303, and 89306) were negative, and not easily interpretable since there were no active control arms," he stated, "I feel there were sufficient reasons to speculate about the negative outcomes and, therefore, not count these studies against citalopram."
Dr Laughman also counted 2 relapse prevention trials as effective to support the drug's approval. "Overall," he wrote, "I consider these results sufficient to support claims of both short-term and long-term antidepressant effectiveness of citalopram."
However, other FDA officials were not so eager to stretch the truth about the weak studies with medical professionals and consumers. For instance, a May 4, 1998 memo by Paul Leber, Director of the Division of Neuropharmacological Drug Projects, on the subject of "Approvable Action on Forrest Laboratories NDA 20-822 Celexa," said the pubic had a right to know the truth about all the trials submitted to the FDA for the approval of Celexa.
He advised that the drug labeling should not only describe the trials that showed Celexa's adequate effects; but should also describe the "well controlled clinical studies that failed to do so."
Dr Leber specifically pointed out that Study 86141, Study 89303, and Study 89306, all failed to provide results confirming the positive findings of Studies 85 and 91206, the two clinical trials that Dr Laughman listed to support the approval of Celexa.
"I am aware that clinical studies often fail to document the efficacy of effective drugs," Dr Leber wrote, "but I doubt the public, or even the majority of medical community, are aware of this fact," he said.
"I believe that labeling," he stated, "that selectively describes positive studies and excludes mention of negative ones can be viewed as being potentially "false and misleading.""
"I believe it is useful for the prescriber, patient, and 3rd party payer to know," Dr Leber wrote, "without having to gain access to official FDA review documents, that citalopram's antidepressants effects were not detected in every controlled clinical trial intended to demonstrate those effects."
"I am persuaded," he stated, "they not only have a right to know, but should know."
When Forest Labs got Lexapro approved in 2002, it was nothing more than a chemically altered version of Celexa, and Forest Labs spent a fortune on persuading doctors to switch patients to Lexapro before its top selling drug Celexa lost its patent protection in 2004.
At the time, Forest could point to only one lone study, that the company itself paid to have published that claimed Lexapro was any better than Celexa. The paper, by Dr Jack Gorman, of the Mount Sinai School of Medicine, pooled the results of three studies and concluded that Lexapro "may have a faster onset" than Celexa, according to a report by Melody Peterson in the November 22, 2002 New York Times.
Dr Gorman's paper was published in CNS Spectrums, a medical journal he edits, and Forest paid Medworks Media, a small medical marketing company that publishes the journal, to print the article in a special supplement.
Other researchers disagreed with the study results. "The Medical Letter, a nonprofit newsletter respected for its independence from the pharmaceutical industry," Ms Petersen reports, "reviewed the same clinical trials as Dr. Gorman and concluded ... that Lexapro had not been shown to be better than any other antidepressant, including Celexa."
As for Paxil, in June 2004, New York State Attorney General, Eliot Spitzer, charged GlaxoSmithKline, with fraud for hiding studies that "not only failed to show any benefit for the drug in children but demonstrated that children taking Paxil were more likely to become suicidal than those taking a placebo."
According to Mr Spitzer, Glaxo published only one of 5 studies it conducted, and even that one showed mixed results.
Prozac (fluoxetine) was also known to be ineffective before it was approved for use in the US. While serving as an expert witness in a lawsuit, psychiatrist and SSRI expert, Dr Peter Breggin, author of, "Talking Back to Prozac," reviewed a July 1985 in-house analysis by its maker, Eli Lilly, that showed Prozac had failed to demonstrate efficacy in clinical trials with patients taking Prozac verses a placebo or a tricyclic antidepressant.
"When this potential economic disaster for Eli Lilly was discovered," Dr Beggin reports, "the FDA allowed the company to include in its efficacy data those patients who had been illegally treated with concomitant benzodiazepine tranquilizers in order to calm their over stimulation."
"Basically, Prozac was approved in combination with addictive benzodiazepines such as Ativan, Xanax, and Valium," he says, "but neither the FDA nor the drug company revealed this information."
"With these patients included," he states, "statistical manipulations enabled the FDA to find the drug marginally approvable."
An internal Lilly document dated March 29, 1985, says, "The benefits vs. risks considerations for fluoxetine currently does not fall clearly in favor of the benefits."
Medwatch is the reporting system by which adverse events involving prescription drugs are reported to the FDA. Within one decade of Prozac's arrival on the market, there were 39,000 adverse event reports submitted to Medwatch and that number is said to represent only about 1% of the actual number of adverse events, according to an April 22, 2006 report by the Citizens Commission on Human Rights.
Serious questions about the possible link between suicide and SSRIs began in 1990, when Martin Teicher, of McLean Hospital in Massachusetts, reported on 6 patients who he said experienced "intense, violent suicidal thoughts" after taking Prozac.
He offered three possible theories for the increased suicidality: (1) SSRIs gave patients more energy before lifting their depression, allowing them to act on a suicidal impulse; (2) the drugs worsened depression in a small subset of patients; or (3) SSRIs caused a state of agitation and restlessness.
In a February 10, 1990, report titled, "Emergence of Intense Suicidal Preoccupation During Fluoxetine Treatment," Dr Teicher said, "The purpose of this report is to suggest the surprising possibility that fluoxetine may induce suicidal ideation in some patients."
"In our experience," he wrote, "this side effect has occurred in 3.5% of patients receiving fluoxetine."
Throughout the 1990s, Eli Lilly publicly denied that Prozac was associated with suicide or violence, but by the year 2000, the company had quietly paid an estimated $50 million to settle over 30 lawsuits, according to an Indianapolis Star investigation.
When reviewing Lilly's studies on Prozac, Dr Breggin found that there were 12 suicide attempts in the Prozac group verses only one in the placebo group and one in the tricyclic antidepressant group, but that many of the suicide attempts were hidden under false categories.
"Even after the company winnowed out six of the suicide attempts," Dr Breggin says, "the remaining 6:1 ratio was alarming."
He also reviewed a November 8, 1998, study titled, "Activation and Sedation in Fluoxetine Clinical Trials," that showed a 38% rate of stimulation in the patients taking Prozac, even though, he says, many patients were sedated and many parameters of stimulation were not counted.
Another group of documents that he examined, contained a study conducted by the FDA on increased spontaneous post marketing reports of "hostility" and "intentional injury" by patients on Prozac. "These documents," Dr Breggin says, "were generated shortly before the 1991 FDA PDAC meeting that evaluated antidepressant-induced suicidality."
For this study, the FDA used the antidepressant, trazodone, as a control and found a 24-fold relative increase of reports of hostility and intentional injury per prescription of Prozac when compared to patients on trazodone.
"The spike in Prozac reports," Dr Breggins says, "occurred even before any public controversy surrounding Prozac and violence."
The documents he reviewed also contained graphs showing a 40-fold relative increase in reports of suicide attempts, overdose, and psychotic depression, in patients on Prozac compared to patients on trazodone.
"In one memo," Dr Breggin reports, "a Lilly employee expresses shame and regret about hiding this data."
In the case where Dr Breggin testified, Lilly was able to have the records sealed by the court where they remained hidden for roughly 10 years.
On April 10, 2004, the British Medical Journal, citing Jurendi et al, criticized the authors of studies on SSRIs for exaggerating benefits and downplaying their harm and noted a clinical trial of 93 children on Paxil that produced 11 serious adverse events, including 7 hospitalizations, compared to only two in children in the placebo group.
But the Paxil suicide risk does not only apply to children. An August 22, 2005, study by Norwegian researchers found that Paxil also increases suicide risk in adults. In the study of over 1,500 adults, 7 Paxil patients attempted suicide compared to only one attempt in the group of patients on a placebo. The researchers recommended that the warning not to prescribe Paxil to children should be extended to adults.
In Insight News, on October 4, 2002, investigative reporter, Kelly Patricia O'Meara, author of, "Psyched Out, How Psychiatry Sells Mental Illness and Pushes Pills That Kill (2006)," revealed a study conducted by Dr Arif Khan, medical director of the Northwest Clinical Research Center in Bellevue, Washington, that disclosed the number of suicides committed or attempted by patients in the clinical trials on SSRIs, that were kept hidden from doctors and consumers.
For the study, Dr Khan examined the official clinical drug-trial data for all SSRIs approved by the FDA between 1985 and 2000.
According to Ms O'Meara, the rate of suicides in the general public is 11 in 100,000, but the incidence rate for people participating in the SSRI trials was 718 for every 100,000. Dr Kahn's research also revealed that nearly 4% of study participants attempted suicide within the following year.
As for weighing the benefits against the above risks, the British Medical Journal published a study on July 16, 2005, by Joanna Moncrieff, senior lecturer in psychiatry at University College London, that found SSRIs no more effective than a placebo in reducing depression.
The study also found that trials on SSRIs with negative results were less likely to be published than those with positive results, and that even in the published trials, negative outcomes were often not presented.
Dr Moncrieff said she found "no good evidence that these drugs work."
FDA Advisory Committee Schedules Hearing on SSRIs and Suicide
Evelyn Pringle December 5, 2006
The FDA's Psychopharmacologic Drugs Advisory Committee will hold a public hearing on December 13, 2006, to review the adult selective serotonin reuptake inhibitor (SSRI) studies on the increased risk of suicide associated with the antidepressants.
The panel is expected to vote on whether the risk of suicidality in adults should be included in a Black Box warning on all SSRI labels, including Paxil, Prozac, Zoloft, Lexapro, and Celexa.
The fact is, the FDA has known about the increased suicide risk associated with SSRIs for over 15 years as evidenced at a September 20, 1991, hearing, at which FDA official Dr Robert Temple stated:
"The discussion we heard earlier showed that people who commit suicide are highly likely to have a diagnosis of depression, which means that somebody identified them as in a high-risk category.
"But there were still a significant number of people who committed suicide without having that sort of diagnosis and I guess I would like some advice or discussion on who those people were.
"The anecdotes that one hears that are most evocative to me anyway are not the ones where people who have a 20-year history of suicidal ideation and then finally do it - that is not too surprising - it is where they assert that there has never been anything in their minds like that before and yet now they have suddenly become excessively concerned with suicide and may even do it."
Yet here it is nearing the end of 2006, and the FDA is still refusing to provide a logical answer to explain why people who were not depressed before taking SSRIs would all of a sudden commit suicide after taking the drugs.
Top experts from all over the US and abroad will be testifying at the hearing and for many it will be a repeat performance. For instance, Baum Hedlund attorney, Karen Barth-Menzies, will be testifying again. She has been battling SSRI makers for over a decade and as a result, she has obtained internal company documents that show the SSRI makers were fully aware of the increased suicide risks associated with SSRIs but instead of warning the public, they continued to promote SSRIs as safe and effective with children and adults.
"Through our Paxil litigation," Ms Menzies says, "we obtained documents that show a seriously troubling mentality of profit over safety and a callous disregard for the welfare of children."
"That's about as reprehensible as you can get," Ms Menzies says.
"The manufacturers of the SSRIs," she states, "have continuously and adamantly denied even the possibility of a causal connection between the SSRIs and suicide, and, instead, have blamed the victim and the 'disease.'"
"This is notwithstanding clear evidence," Ms Menzies says, "very early on in the clinical trials of these drugs that they can cause these problems."
"We have documents," she notes, "obtained through discovery in our litigation showing that there was an awareness of the problem as far back as the late 1970s, long before the first SSRI, Prozac, was approved for marketing in this country."
Over the past 10 years, in addition to representing thousands of clients in SSRI lawsuits, Ms Menzies has been a tireless advocate working to increase public awareness about the host of health risks now known to be associated with SSRIs.
After listening to her testimony before the FDA Advisory Committee in 2004, a California state Senator invited Ms Menzies to work on legislation designed to inform California healthcare providers and parents about the increased risk of suicidality in children and adolescents taking SSRIs.
She also testified at a hearing in August 2004, before the California State Senate and called for better patient informed consent on the risks associated with SSRIs.
Ms Menzies has given presentations at medical conferences in the US and other countries to warn healthcare professionals about the dangers of SSRIs.
In fact, she gave one presentation that directly addressed the FDA's mishandling of the SSRI matter titled, "Federal Preemption - How the U.S. Food & Drug Administration Has Become an Advocate for the Drug Industry Against the Consumers It Has a Duty to Protect" - SSRIs and Collisions Between Medical, Legal and Regulatory Worlds, at the 29th International Congress On Law and Mental Health, in Paris, France, on July 2-8, 2005.
Another one of the world's most highly respected experts on SSRIs, Dr David Healy, a professor at the Department of Psychological Medicine, at Cardiff University in North Wales, will be traveling from the UK to testify. His appearance will also be a repeat performance.
Dr Healy states that he will testify about the manipulation of the scientific data on SSRIs. "We have here," he says, "the greatest divide in medicine between the raw data on an issue on the one side and the published accounts purporting to represent those data on the other."
"The divide," he says, "it is important to note, only came to light as a result of the efforts of journalists and lawyers."
"No clinician or scientist had a hand in questioning the validity of the 'science'," he points out.
The most famous fraudulent study involving SSRIs is GlaxoSmithKline's study 329, involving Paxil. The study stated that Paxil was safe, well-tolerated and effective in children, but noted that some children became emotionally "labile" while taking the drug.
"In the published version of 329," Dr Healy points out, "suicidality vanishes under a carpet of emotional lability."
Few readers of this paper, academic or lay, he says, would have realized what lay behind this term as it appeared in the paper. "The question of what was happening to children," Dr Healy says, "deemed to have become emotionally labile, was picked up by journalists and lawyers rather than scientists or regulators."
As a result of Glaxo's application for a license for the use of Paxil to treat children with nervous disorders, he explains, the raw data from clinical trials were lodged with a number of national regulators.
"Within a fortnight of seeing the raw data in May 2003," Dr Healy says, "after the events lying behind the term emotional lability had been clarified, the regulators in the UK issued a warning against the use of Paxil for minors."
A few weeks later, he notes, Glaxo wrote to all doctors warning that Paxil was linked to suicidality and that withdrawal from the drug was also linked to an apparent doubling of the rate of suicidality.
"This reassessment of the data does not however represent a triumph of scientific method," Dr Healy says, "it indicates rather a crisis triggered by media concerns."
The final nail in the coffin as far as selling SSRIs to kids in the UK, came in December 2003, when British regulators issued a position statement that said none of the SSRIs had demonstrated efficacy in treating depression in children.
By far the most damning revelations about what SSRI makers knew about the link between SSRIs and suicide came when the British Medical Journal received internal company documents from an anonymous source that left no doubt that Eli Lilly knew about the suicide risks with Prozac years before the drug was FDA approved.
After receiving the documents, the BMJ sent them to officials at the FDA, and to US Congressman, Maurice Hinchey, who in turn sent them to psychiatrist, Dr Peter Breggin, a court-certified expert on SSRIs, and author of, "Talking Back to Prozac," and "The Anti-Depressant Fact Book."
After examining the documents, Dr Breggin confirmed their authenticity as those that he had evaluated in the early 1990s when he served as an expert witness in Prozac litigation and discussed when testifying during a trial in 1994.
Evidence of the hidden studies showing the suicide risk can be found in a May 1984 document presented at trial which states regarding Prozac: "During the treatment with the preparation 16 suicide attempts were made, 2 of these with success."
"As patients with a risk of suicide were excluded from the studies," the document says, "it is probable that this high proportion can be attributed to an action of the preparation."
In fact, a March 29, 1985 document says that the rate of suicide with Prozac was 5.6 times higher than with the other medication imipramine and went on to state:
"The benefits vs. risks considerations for fluoxetine currently does not fall clearly in favor of the benefits. Therefore, it is of the greatest importance that it be determined whether there is a particular subgroup of patients who respond better to fluoxetine than to imipramine, so that the higher incidence of suicide attempts may be tolerable."
On November 13, 1990, a memo from a Lilly employee in Germany, Claude Bouchy, to another Lilly employee, Leigh Thompson, regarding the adverse drug event reporting of suicide and Prozac written in response to Lilly's request that he change the event "suicidal ideation" to "depression," Mr Bouchy writes:
"Hans (Lilly employee) has medical problems with these directions and I have great concerns about it.
"I do not think I could explain to the BGA, a judge, to a reporter or even to my family why we would do this especially on the sensitive issue of suicide and suicidal ideation."
A second memo dated November 14, 1990, from Mr Bouchy to Leigh Thompson about adverse drug event reporting states: "I personally wonder whether we are really helping the credibility of an excellent ADE system by calling overdose what a physician reports as suicide attempt and by calling depression what a physician is reporting as suicide ideation."
The documents also reveal how worried Lilly was about the commercial impact to the company if the truth about the Prozac-induced suicides got out. A February 7, 1990 Leigh Thompson Memo, says, "Anything that happens in the UK can threaten this drug in the US and worldwide. We are now expending enormous efforts fending off attacks because of (1) relationship to murder and (2) inducing suicidal ideation."
On February 7, 1990, a Leigh Thompson memo also says, "I hope Patrick (a Lilly employee) realizes that Lilly can go down the tubes if we lose Prozac and just one event in the UK can cost us that."
Dr Breggin says that after he testified in the trial in 1994, these documents seemed to just disappear, until they were handed over to the BMJ.
The FDA's Psychopharmacologic Drugs Advisory Committee will hold a public hearing on December 13, 2006, to review the adult selective serotonin reuptake inhibitor (SSRI) studies on the increased risk of suicide associated with the antidepressants.
The panel is expected to vote on whether the risk of suicidality in adults should be included in a Black Box warning on all SSRI labels, including Paxil, Prozac, Zoloft, Lexapro, and Celexa.
The fact is, the FDA has known about the increased suicide risk associated with SSRIs for over 15 years as evidenced at a September 20, 1991, hearing, at which FDA official Dr Robert Temple stated:
"The discussion we heard earlier showed that people who commit suicide are highly likely to have a diagnosis of depression, which means that somebody identified them as in a high-risk category.
"But there were still a significant number of people who committed suicide without having that sort of diagnosis and I guess I would like some advice or discussion on who those people were.
"The anecdotes that one hears that are most evocative to me anyway are not the ones where people who have a 20-year history of suicidal ideation and then finally do it - that is not too surprising - it is where they assert that there has never been anything in their minds like that before and yet now they have suddenly become excessively concerned with suicide and may even do it."
Yet here it is nearing the end of 2006, and the FDA is still refusing to provide a logical answer to explain why people who were not depressed before taking SSRIs would all of a sudden commit suicide after taking the drugs.
Top experts from all over the US and abroad will be testifying at the hearing and for many it will be a repeat performance. For instance, Baum Hedlund attorney, Karen Barth-Menzies, will be testifying again. She has been battling SSRI makers for over a decade and as a result, she has obtained internal company documents that show the SSRI makers were fully aware of the increased suicide risks associated with SSRIs but instead of warning the public, they continued to promote SSRIs as safe and effective with children and adults.
"Through our Paxil litigation," Ms Menzies says, "we obtained documents that show a seriously troubling mentality of profit over safety and a callous disregard for the welfare of children."
"That's about as reprehensible as you can get," Ms Menzies says.
"The manufacturers of the SSRIs," she states, "have continuously and adamantly denied even the possibility of a causal connection between the SSRIs and suicide, and, instead, have blamed the victim and the 'disease.'"
"This is notwithstanding clear evidence," Ms Menzies says, "very early on in the clinical trials of these drugs that they can cause these problems."
"We have documents," she notes, "obtained through discovery in our litigation showing that there was an awareness of the problem as far back as the late 1970s, long before the first SSRI, Prozac, was approved for marketing in this country."
Over the past 10 years, in addition to representing thousands of clients in SSRI lawsuits, Ms Menzies has been a tireless advocate working to increase public awareness about the host of health risks now known to be associated with SSRIs.
After listening to her testimony before the FDA Advisory Committee in 2004, a California state Senator invited Ms Menzies to work on legislation designed to inform California healthcare providers and parents about the increased risk of suicidality in children and adolescents taking SSRIs.
She also testified at a hearing in August 2004, before the California State Senate and called for better patient informed consent on the risks associated with SSRIs.
Ms Menzies has given presentations at medical conferences in the US and other countries to warn healthcare professionals about the dangers of SSRIs.
In fact, she gave one presentation that directly addressed the FDA's mishandling of the SSRI matter titled, "Federal Preemption - How the U.S. Food & Drug Administration Has Become an Advocate for the Drug Industry Against the Consumers It Has a Duty to Protect" - SSRIs and Collisions Between Medical, Legal and Regulatory Worlds, at the 29th International Congress On Law and Mental Health, in Paris, France, on July 2-8, 2005.
Another one of the world's most highly respected experts on SSRIs, Dr David Healy, a professor at the Department of Psychological Medicine, at Cardiff University in North Wales, will be traveling from the UK to testify. His appearance will also be a repeat performance.
Dr Healy states that he will testify about the manipulation of the scientific data on SSRIs. "We have here," he says, "the greatest divide in medicine between the raw data on an issue on the one side and the published accounts purporting to represent those data on the other."
"The divide," he says, "it is important to note, only came to light as a result of the efforts of journalists and lawyers."
"No clinician or scientist had a hand in questioning the validity of the 'science'," he points out.
The most famous fraudulent study involving SSRIs is GlaxoSmithKline's study 329, involving Paxil. The study stated that Paxil was safe, well-tolerated and effective in children, but noted that some children became emotionally "labile" while taking the drug.
"In the published version of 329," Dr Healy points out, "suicidality vanishes under a carpet of emotional lability."
Few readers of this paper, academic or lay, he says, would have realized what lay behind this term as it appeared in the paper. "The question of what was happening to children," Dr Healy says, "deemed to have become emotionally labile, was picked up by journalists and lawyers rather than scientists or regulators."
As a result of Glaxo's application for a license for the use of Paxil to treat children with nervous disorders, he explains, the raw data from clinical trials were lodged with a number of national regulators.
"Within a fortnight of seeing the raw data in May 2003," Dr Healy says, "after the events lying behind the term emotional lability had been clarified, the regulators in the UK issued a warning against the use of Paxil for minors."
A few weeks later, he notes, Glaxo wrote to all doctors warning that Paxil was linked to suicidality and that withdrawal from the drug was also linked to an apparent doubling of the rate of suicidality.
"This reassessment of the data does not however represent a triumph of scientific method," Dr Healy says, "it indicates rather a crisis triggered by media concerns."
The final nail in the coffin as far as selling SSRIs to kids in the UK, came in December 2003, when British regulators issued a position statement that said none of the SSRIs had demonstrated efficacy in treating depression in children.
By far the most damning revelations about what SSRI makers knew about the link between SSRIs and suicide came when the British Medical Journal received internal company documents from an anonymous source that left no doubt that Eli Lilly knew about the suicide risks with Prozac years before the drug was FDA approved.
After receiving the documents, the BMJ sent them to officials at the FDA, and to US Congressman, Maurice Hinchey, who in turn sent them to psychiatrist, Dr Peter Breggin, a court-certified expert on SSRIs, and author of, "Talking Back to Prozac," and "The Anti-Depressant Fact Book."
After examining the documents, Dr Breggin confirmed their authenticity as those that he had evaluated in the early 1990s when he served as an expert witness in Prozac litigation and discussed when testifying during a trial in 1994.
Evidence of the hidden studies showing the suicide risk can be found in a May 1984 document presented at trial which states regarding Prozac: "During the treatment with the preparation 16 suicide attempts were made, 2 of these with success."
"As patients with a risk of suicide were excluded from the studies," the document says, "it is probable that this high proportion can be attributed to an action of the preparation."
In fact, a March 29, 1985 document says that the rate of suicide with Prozac was 5.6 times higher than with the other medication imipramine and went on to state:
"The benefits vs. risks considerations for fluoxetine currently does not fall clearly in favor of the benefits. Therefore, it is of the greatest importance that it be determined whether there is a particular subgroup of patients who respond better to fluoxetine than to imipramine, so that the higher incidence of suicide attempts may be tolerable."
On November 13, 1990, a memo from a Lilly employee in Germany, Claude Bouchy, to another Lilly employee, Leigh Thompson, regarding the adverse drug event reporting of suicide and Prozac written in response to Lilly's request that he change the event "suicidal ideation" to "depression," Mr Bouchy writes:
"Hans (Lilly employee) has medical problems with these directions and I have great concerns about it.
"I do not think I could explain to the BGA, a judge, to a reporter or even to my family why we would do this especially on the sensitive issue of suicide and suicidal ideation."
A second memo dated November 14, 1990, from Mr Bouchy to Leigh Thompson about adverse drug event reporting states: "I personally wonder whether we are really helping the credibility of an excellent ADE system by calling overdose what a physician reports as suicide attempt and by calling depression what a physician is reporting as suicide ideation."
The documents also reveal how worried Lilly was about the commercial impact to the company if the truth about the Prozac-induced suicides got out. A February 7, 1990 Leigh Thompson Memo, says, "Anything that happens in the UK can threaten this drug in the US and worldwide. We are now expending enormous efforts fending off attacks because of (1) relationship to murder and (2) inducing suicidal ideation."
On February 7, 1990, a Leigh Thompson memo also says, "I hope Patrick (a Lilly employee) realizes that Lilly can go down the tubes if we lose Prozac and just one event in the UK can cost us that."
Dr Breggin says that after he testified in the trial in 1994, these documents seemed to just disappear, until they were handed over to the BMJ.
Tuesday, August 3, 2010
Psych Drugs - Doctors Serve As Middle-Man Pushers
Evelyn Pringle February 21, 2006
Although peddling psychiatric drugs for off-label treatment of every ailment known to man is highly profitable, it is also illegal. Marketing schemes that increase the rates at which drugs are prescribed for off-label use, result in the sale of drugs that have not been proven safer or superior to FDA approved medications already on the market.
That said, it's time to quit blaming the pharmaceutical industry exclusively for off-labeling marketing. The fact remains, that drug makers could not sell their new and relatively untested drugs if not for the doctors who take on the role of middle-man pusher.
Since the arrival of selective serotonin reuptake inhibitors antidepressants (SSRIs), and atypical antipsychotics on the market, countless studies have shown the so-called "new generation" of psychiatric drugs to be ineffective and dangerous. But for years, drug companies have successfully manipulated data, suppressed negative studies, and reported only the clinical trials with positive results.
However, by now plenty of warnings have been issued about these drugs, and doctors who continue to prescribe them due to financial incentives from pharma, or because they happen to be approved by the compromised FDA, should not be let off the hook. If it takes a few highly publicized lawsuits against prescribing physicians to knock some sense into these doctors, so be it.
Medical professionals need to start conducting their own research which means doing more than relying on medical journal abstracts on the internet that for the most part, are formatted to report misleading claims without mentioning the contradictory data.
On January 13, 2005 WebMD Medical News reported a government study that showed more Americans than ever are being treated for substance abuse, depression, and other mental health disorders, but the treatment they are getting is increasingly limited to prescription drugs alone.
The study assessed changing patterns in the treatment of mental illnesses from the mid-1990s to 2001, and determined that mental health drug costs rose 20% each year.
According to Economist Samuel H Zuvekas, PhD, who conducted the analysis, about 80% of the growth in expenditures can be explained by the increase in the use of SSRIs and other antidepressants, and high-priced schizophrenia drugs called "atypical antipsychotics."
Worldwide, sales of anti-psychotics went from $263 million in 1986 to $8.6 billion in 2004 and antidepressant sales went from $240 million in 1986, to $11.2 billion in 2004, For these two classes of drugs combined, sales went from $500 million in 1986 to nearly $20 billion in 2004, a 40-fold increase, according to Robert Whitaker, best-selling author of Mad in America.
For over 15 years, millions of Americans have been prescribed SSRIs for off-label treatment of a multitude of newly invented disorders. Mr Whitaker says, "what we're seeing is nothing more than the creation of a larger market for drugs."
"If you think about it," he explained during an August 2005, interview with Street Spirit, "as long as we draw as big a circle as possible, and expand the boundaries of mental illness, psychiatry can have more clients and sell more drugs."
"So there's a built-in economic incentive to define mental illness in as broad terms as possible," he continued, "and to find ordinary, distressing emotions or behaviors that some people may not like and label them as mental illness."
Prozac is the only SSRI approved by the FDA for treating depression in children. It is reportedly the only SSRI shown to be effective in two pediatric trials, the number required to obtain FDA approval.
But to put the term "effective" into perspective, all a drug has to do to pass 2 trials, is show it had better results in children treated with the SSRI than children taking a placebo. The trick is that a company can do 100 trials to get the necessary result if need be. It stands to reason that sooner or later the SSRI is bound to do better than a placebo when the odds are 50-50.
However, over the past couple of years, this practice has been coming under scrutiny. GlaxoSmithKline was nailed for fraud in 2004, by New York State Attorney General, Eliot Spitzer for hiding studies that "not only failed to show any benefit for the drug in children but demonstrated that children taking Paxil were more likely to become suicidal than those taking a placebo."
The suit said the company had conducted at least 5 studies on the use of Paxil on children, but only published and disseminated the results of one.
Spitzer drew attention to the fraud charges by publishing a 1998 e-mail in which Glaxo officials discussed the studies and the need to "effectively manage the dissemination of these data in order to minimize any potential negative commercial impact."
Although Paxil was never approved to treat depression in children, according to Spitzer, in 2002, doctors prescribed the drug off-label to children two million times, the same year that Paxil was Glaxo's top seller, with sales of $3.8 billion.
To settle the charges, Glaxo agreed to pay $2.5 million to the State of New York.
An April 10, 2004 article in the British Medical Journal, citing Jurendi et al, criticized the authors of published studies on SSRIs for exaggerating benefits and downplaying their harm. As an example, Jurendi noted that a trial of 93 kids on Paxil, produced 11 serious adverse events compared with only two in the placebo group. Despite this, and the fact that 7 of the Paxil patients were admitted to the hospital, the authors of the study claimed Paxil "was generally well tolerated in this adolescent population, and most adverse effects were not serious."
As for the effectiveness of SSRIs, in June, 2005, the Washington Post reported: "Despite a dramatic increase in treatment of psychiatric disorders during the past 10 years, there has been no decrease in the rate of suicidal thoughts and behavior among adults, according to a federal study primarily funded by the National Institute of Mental Health."
Although studies have shown atypical antipsychotics to be associated with a growing number of serious adverse effects, doctors continue to be prescribe them off-label to treat a host of health problems, for senior citizens, persons in state institutions, and children.
In 2004, atypicals became the fourth-highest-grossing drugs in the US, with $3.4 billion of their total sales funded by state Medicaid programs, according to the article Medicating Aliah, in the May 2005 issue of Mother Jones Magazine.
Recent research has shown that nursing home residents are being fed antipsychotics in record numbers. A June 13, 2005, study published in the Archives of Internal Medicine examined the quality of antipsychotic prescriptions in approximately 2.5 million Medicaid beneficiaries in nursing homes and found that "over half (58.2%)," received antipsychotic drugs that exceeded the maximum recommended dosage, received duplicate therapy, or under the guidelines, had inappropriate indications for the medications to begin with.
The study found that more than 200,000 nursing home residents received antipsychotic therapy but had "no appropriate indications for use."
Pharma will stop at nothing when it comes to making money off children. On April 25, 2005, the Ohio Columbus Dispatch reported an investigation of state Medicaid records that found 18 newborn to 3 years-old babies in Ohio had been prescribed antipsychotic drugs in July 2004.
During an investigation of children under state care in Pennsylvania, Dr Stefan Kruszewski, a Harvard trained psychiatrist, found "cases where children were placed in state-funded residential treatment facilities, sometimes for years, and were heavily drugged with the new antipsychotics and anticonvulsants."
Reports of the adverse effects of the drugs on children are beginning to emerge. The Children's Hospital of Philadelphia recently found that 19% of newly diagnosed Type 2 diabetic children were being treated with psychiatric drugs like Zyprexa, Risperdal, Geodon, Seroquel, Clozaril, and Abilify, according to Robert F. Kennedy Jr vs the Medical Elite, by Mark Sircus Ac, OMD in June 22, 2005.
"Many of these drugs carry black box warning to alert MD's about the dangers of diabetes," Mr Sircus pointed out. "The most studied adverse effect of the newer generation of antipsychotics is their association with hyperglycemia, in some cases leading to ketoacidosis, coma, or death," he wrote.
According to Dr Kruszewski, the new atypicals substantially increase the risk of obesity, diabetes type II, hypertension, heart attacks, cardiovascular complications, and stroke.
"The drug makers had this information and simply ignored the problem," he says.
Dr Kruszewski is apparently correct judging by hidden studies that have come to light. After years of prescribing Risperdal, for off-label use by millions of patients in all age groups, on July 24, 2004, the Miami Herald reported the "maker of a billion-dollar antipsychotic medication has acknowledged misleading doctors and other healthcare providers about the safety of its product, minimizing potentially deadly side effects."
As it turns out, the maker of Risperdal, had 2 billion good reasons to hide the dangers associated with the drug because Janssen earns about $2.1 billion in annual sales from Risperdal, according to the Miami Herald.
During his interview with Street Spirit, Mr Whitaker summed up the devastating effects on society as a result of the marketing practices promoting the sale of the new psych drugs:
"Unfortunately, the cost is dishonesty in our scientific literature, the corruption of the FDA, and the absolute harm done to children in this country drawn into this system, and an increase of 150,000 newly disabled people every year in the United States for the last 17 years," he said. "That's an incredible record of harm done."
But worst of all, Mr Whitaker says: "No one says that the mental health of the American people is getting better."
Although peddling psychiatric drugs for off-label treatment of every ailment known to man is highly profitable, it is also illegal. Marketing schemes that increase the rates at which drugs are prescribed for off-label use, result in the sale of drugs that have not been proven safer or superior to FDA approved medications already on the market.
That said, it's time to quit blaming the pharmaceutical industry exclusively for off-labeling marketing. The fact remains, that drug makers could not sell their new and relatively untested drugs if not for the doctors who take on the role of middle-man pusher.
Since the arrival of selective serotonin reuptake inhibitors antidepressants (SSRIs), and atypical antipsychotics on the market, countless studies have shown the so-called "new generation" of psychiatric drugs to be ineffective and dangerous. But for years, drug companies have successfully manipulated data, suppressed negative studies, and reported only the clinical trials with positive results.
However, by now plenty of warnings have been issued about these drugs, and doctors who continue to prescribe them due to financial incentives from pharma, or because they happen to be approved by the compromised FDA, should not be let off the hook. If it takes a few highly publicized lawsuits against prescribing physicians to knock some sense into these doctors, so be it.
Medical professionals need to start conducting their own research which means doing more than relying on medical journal abstracts on the internet that for the most part, are formatted to report misleading claims without mentioning the contradictory data.
On January 13, 2005 WebMD Medical News reported a government study that showed more Americans than ever are being treated for substance abuse, depression, and other mental health disorders, but the treatment they are getting is increasingly limited to prescription drugs alone.
The study assessed changing patterns in the treatment of mental illnesses from the mid-1990s to 2001, and determined that mental health drug costs rose 20% each year.
According to Economist Samuel H Zuvekas, PhD, who conducted the analysis, about 80% of the growth in expenditures can be explained by the increase in the use of SSRIs and other antidepressants, and high-priced schizophrenia drugs called "atypical antipsychotics."
Worldwide, sales of anti-psychotics went from $263 million in 1986 to $8.6 billion in 2004 and antidepressant sales went from $240 million in 1986, to $11.2 billion in 2004, For these two classes of drugs combined, sales went from $500 million in 1986 to nearly $20 billion in 2004, a 40-fold increase, according to Robert Whitaker, best-selling author of Mad in America.
For over 15 years, millions of Americans have been prescribed SSRIs for off-label treatment of a multitude of newly invented disorders. Mr Whitaker says, "what we're seeing is nothing more than the creation of a larger market for drugs."
"If you think about it," he explained during an August 2005, interview with Street Spirit, "as long as we draw as big a circle as possible, and expand the boundaries of mental illness, psychiatry can have more clients and sell more drugs."
"So there's a built-in economic incentive to define mental illness in as broad terms as possible," he continued, "and to find ordinary, distressing emotions or behaviors that some people may not like and label them as mental illness."
Prozac is the only SSRI approved by the FDA for treating depression in children. It is reportedly the only SSRI shown to be effective in two pediatric trials, the number required to obtain FDA approval.
But to put the term "effective" into perspective, all a drug has to do to pass 2 trials, is show it had better results in children treated with the SSRI than children taking a placebo. The trick is that a company can do 100 trials to get the necessary result if need be. It stands to reason that sooner or later the SSRI is bound to do better than a placebo when the odds are 50-50.
However, over the past couple of years, this practice has been coming under scrutiny. GlaxoSmithKline was nailed for fraud in 2004, by New York State Attorney General, Eliot Spitzer for hiding studies that "not only failed to show any benefit for the drug in children but demonstrated that children taking Paxil were more likely to become suicidal than those taking a placebo."
The suit said the company had conducted at least 5 studies on the use of Paxil on children, but only published and disseminated the results of one.
Spitzer drew attention to the fraud charges by publishing a 1998 e-mail in which Glaxo officials discussed the studies and the need to "effectively manage the dissemination of these data in order to minimize any potential negative commercial impact."
Although Paxil was never approved to treat depression in children, according to Spitzer, in 2002, doctors prescribed the drug off-label to children two million times, the same year that Paxil was Glaxo's top seller, with sales of $3.8 billion.
To settle the charges, Glaxo agreed to pay $2.5 million to the State of New York.
An April 10, 2004 article in the British Medical Journal, citing Jurendi et al, criticized the authors of published studies on SSRIs for exaggerating benefits and downplaying their harm. As an example, Jurendi noted that a trial of 93 kids on Paxil, produced 11 serious adverse events compared with only two in the placebo group. Despite this, and the fact that 7 of the Paxil patients were admitted to the hospital, the authors of the study claimed Paxil "was generally well tolerated in this adolescent population, and most adverse effects were not serious."
As for the effectiveness of SSRIs, in June, 2005, the Washington Post reported: "Despite a dramatic increase in treatment of psychiatric disorders during the past 10 years, there has been no decrease in the rate of suicidal thoughts and behavior among adults, according to a federal study primarily funded by the National Institute of Mental Health."
Although studies have shown atypical antipsychotics to be associated with a growing number of serious adverse effects, doctors continue to be prescribe them off-label to treat a host of health problems, for senior citizens, persons in state institutions, and children.
In 2004, atypicals became the fourth-highest-grossing drugs in the US, with $3.4 billion of their total sales funded by state Medicaid programs, according to the article Medicating Aliah, in the May 2005 issue of Mother Jones Magazine.
Recent research has shown that nursing home residents are being fed antipsychotics in record numbers. A June 13, 2005, study published in the Archives of Internal Medicine examined the quality of antipsychotic prescriptions in approximately 2.5 million Medicaid beneficiaries in nursing homes and found that "over half (58.2%)," received antipsychotic drugs that exceeded the maximum recommended dosage, received duplicate therapy, or under the guidelines, had inappropriate indications for the medications to begin with.
The study found that more than 200,000 nursing home residents received antipsychotic therapy but had "no appropriate indications for use."
Pharma will stop at nothing when it comes to making money off children. On April 25, 2005, the Ohio Columbus Dispatch reported an investigation of state Medicaid records that found 18 newborn to 3 years-old babies in Ohio had been prescribed antipsychotic drugs in July 2004.
During an investigation of children under state care in Pennsylvania, Dr Stefan Kruszewski, a Harvard trained psychiatrist, found "cases where children were placed in state-funded residential treatment facilities, sometimes for years, and were heavily drugged with the new antipsychotics and anticonvulsants."
Reports of the adverse effects of the drugs on children are beginning to emerge. The Children's Hospital of Philadelphia recently found that 19% of newly diagnosed Type 2 diabetic children were being treated with psychiatric drugs like Zyprexa, Risperdal, Geodon, Seroquel, Clozaril, and Abilify, according to Robert F. Kennedy Jr vs the Medical Elite, by Mark Sircus Ac, OMD in June 22, 2005.
"Many of these drugs carry black box warning to alert MD's about the dangers of diabetes," Mr Sircus pointed out. "The most studied adverse effect of the newer generation of antipsychotics is their association with hyperglycemia, in some cases leading to ketoacidosis, coma, or death," he wrote.
According to Dr Kruszewski, the new atypicals substantially increase the risk of obesity, diabetes type II, hypertension, heart attacks, cardiovascular complications, and stroke.
"The drug makers had this information and simply ignored the problem," he says.
Dr Kruszewski is apparently correct judging by hidden studies that have come to light. After years of prescribing Risperdal, for off-label use by millions of patients in all age groups, on July 24, 2004, the Miami Herald reported the "maker of a billion-dollar antipsychotic medication has acknowledged misleading doctors and other healthcare providers about the safety of its product, minimizing potentially deadly side effects."
As it turns out, the maker of Risperdal, had 2 billion good reasons to hide the dangers associated with the drug because Janssen earns about $2.1 billion in annual sales from Risperdal, according to the Miami Herald.
During his interview with Street Spirit, Mr Whitaker summed up the devastating effects on society as a result of the marketing practices promoting the sale of the new psych drugs:
"Unfortunately, the cost is dishonesty in our scientific literature, the corruption of the FDA, and the absolute harm done to children in this country drawn into this system, and an increase of 150,000 newly disabled people every year in the United States for the last 17 years," he said. "That's an incredible record of harm done."
But worst of all, Mr Whitaker says: "No one says that the mental health of the American people is getting better."
Thursday, July 29, 2010
Another Shrink Bites the Dust
Evelyn Pringle April 9, 2009
Brown University's Martin Keller is the latest chairman of psychiatry to be replaced since an on-going investigation led by Iowa Republican, Senator Charles Grassley, on behalf of the US Senate Finance Committee, revealed the millions of dollars in undisclosed payments flowing between psychiatric drug makers and "key opinion leaders" in the field of child psychiatry.
In recent months, Charles Nemeroff at Emory University gave up a post he held for 17 years and Alan Schatzberg also stepped down at Stanford as chairs of their psychiatry departments.
In December, Massachusetts General Hospital announced that Harvard's Joseph Biederman would no longer be participating in several drug company funded clinical trials and would limit his speaking and consulting activities with drugs makers, pending the outcome of an inquiry by the hospital of his potential conflict of interests.
Fred Goodwin, the former host of a radio show called "Infinite Minds," broadcast for years by National Pubic Radio, had his radio show thrown off the air last fall.
Keller originally gained fame as the lead author on Paxil Study 329, which claimed Paxil was "generally well tolerated and effective for major depression in adolescents."
However, a later review of the underlying data showed the drug worked no better than a placebo. In addition, among the 93 kids taking Paxil, five suicide-related adverse events occurred compared to only one in the group of 89 kids taking a placebo.
Yet in the 2001 paper published in the Journal of the American Academy of Child and Adolescent Psychiatry, the authors reported that only one child suffered a serious adverse event, a headache, not considered to be related to treatment with Paxil.
Documents obtained in litigation have since revealed that GlaxoSmithKline knew the study was a failure when the data was reviewed 1998, long before the paper appeared in the Journal.
Keller always gets the credit for publishing Study 329, but the fact is, not one of the authors who lent their names to this fraudulent study have come forth to explain their obvious deception.
Therefore, in any discussion of the paper, their names deserve to be highlighted as well and include: Neil Ryan, Michael Strober, Rachel Klein, Stan Kutcher, Boris Birmaher, Owen Hagino, Harold Koplewicz, Gabrielle Carlson, Gregory Clarke, Graham Emslie, David Feinberg, Barbara Geller, Vivek Kusumakar, George Papatheodorou, William Sack, Michael Sweeney, Karen Wagner, Elizabeth Weller, Nancy Winters, Rosemary Oakes, James McCafferty, and Sally Laden.
Senator Grassley's list thus far also includes Harvard's Thomas Spencer and Timothy Wilens; Melissa DelBello at the University of Cincinnati; and Karen Wagner and Augustus John Rush from the University of Texas. Rush recently moved to Singapore.
The Finance Committee has jurisdiction over the Medicare and Medicaid programs and, "Actions taken by key opinion leaders often have profound impact upon the decisions made by taxpayer funded programs like Medicare and Medicaid and the way that patients are treated and funds expended," according to the Senator.
Brown University's Martin Keller is the latest chairman of psychiatry to be replaced since an on-going investigation led by Iowa Republican, Senator Charles Grassley, on behalf of the US Senate Finance Committee, revealed the millions of dollars in undisclosed payments flowing between psychiatric drug makers and "key opinion leaders" in the field of child psychiatry.
In recent months, Charles Nemeroff at Emory University gave up a post he held for 17 years and Alan Schatzberg also stepped down at Stanford as chairs of their psychiatry departments.
In December, Massachusetts General Hospital announced that Harvard's Joseph Biederman would no longer be participating in several drug company funded clinical trials and would limit his speaking and consulting activities with drugs makers, pending the outcome of an inquiry by the hospital of his potential conflict of interests.
Fred Goodwin, the former host of a radio show called "Infinite Minds," broadcast for years by National Pubic Radio, had his radio show thrown off the air last fall.
Keller originally gained fame as the lead author on Paxil Study 329, which claimed Paxil was "generally well tolerated and effective for major depression in adolescents."
However, a later review of the underlying data showed the drug worked no better than a placebo. In addition, among the 93 kids taking Paxil, five suicide-related adverse events occurred compared to only one in the group of 89 kids taking a placebo.
Yet in the 2001 paper published in the Journal of the American Academy of Child and Adolescent Psychiatry, the authors reported that only one child suffered a serious adverse event, a headache, not considered to be related to treatment with Paxil.
Documents obtained in litigation have since revealed that GlaxoSmithKline knew the study was a failure when the data was reviewed 1998, long before the paper appeared in the Journal.
Keller always gets the credit for publishing Study 329, but the fact is, not one of the authors who lent their names to this fraudulent study have come forth to explain their obvious deception.
Therefore, in any discussion of the paper, their names deserve to be highlighted as well and include: Neil Ryan, Michael Strober, Rachel Klein, Stan Kutcher, Boris Birmaher, Owen Hagino, Harold Koplewicz, Gabrielle Carlson, Gregory Clarke, Graham Emslie, David Feinberg, Barbara Geller, Vivek Kusumakar, George Papatheodorou, William Sack, Michael Sweeney, Karen Wagner, Elizabeth Weller, Nancy Winters, Rosemary Oakes, James McCafferty, and Sally Laden.
Senator Grassley's list thus far also includes Harvard's Thomas Spencer and Timothy Wilens; Melissa DelBello at the University of Cincinnati; and Karen Wagner and Augustus John Rush from the University of Texas. Rush recently moved to Singapore.
The Finance Committee has jurisdiction over the Medicare and Medicaid programs and, "Actions taken by key opinion leaders often have profound impact upon the decisions made by taxpayer funded programs like Medicare and Medicaid and the way that patients are treated and funds expended," according to the Senator.
Ghostbusting in Paxil Birth Defect Litigation
Evelyn Pringle March 1, 2010
A month before the first Paxil birth defect trial against GlaxoSmithKline was set to begin, the Associated Press ran the headline, “Glaxo Used Ghostwriting Program to Promote Paxil,” in reporting on a program called “CASPPER,” which allowed doctors to “take credit for medical journal articles mainly written by company consultants.”
“Drug companies frequently hire outside firms to draft a manuscript touting a company's drug, retain a physician to sign off as the author and then find a publisher to unwittingly publish the work,” the Associated Press said on August 19, 2009. “Drug company salespeople often present medical journal articles to physicians as independent proof that their drugs are safe and effective.
Between 2000 and 2002, articles from the CASPPER program appeared in five medical journals. On August 21, 2009, Jim Edwards on BNET, described the CASSPER ghostwriting brochure. The document shows that the intent of CASSPER was to flood the market with ghostwritten information, he said. It stated: “Paxil Product Management has budgeted for 50 articles for 2000.”
The trial in Kilker v Glaxo ended on October 13, 2009, with a jury in Philadelphia finding that Glaxo “negligently failed to warn” the doctor treating Lyam Kilker's mother about Paxil’s risks and the drug was a “factual cause” of Lyam's heart defects. The family was award $2.5 million.
Ghostwriting 101
The world-renowned neuropsychopharmacologist from the UK, Dr David Healy, testified as an expert witness for the plaintiffs in the Kilker trial.
While testifying, Healy explained the process of ghostwriting to the jury. He said ghostwriting probably began seriously in the 1980s. “It's where an article appears under the name of usually a fairly distinguished person in the field,” he testified.
But it involves more than just the true author being concealed, he told the jury. “It's a process where the ghostwriters work for companies who are very good at getting articles into the best journals in the field, like the New England Journal of Medicine, and recruiting some of the best known names in the field to be the apparent authors of the articles.”
“They may come from one of the big named universities like Princeton or whoever, but the actual fact the person who appears to be the author isn't the true author,” he said. “If you were to read the article, you often don't get any hints of who the true author of the article actually was.”
Ghostwriting impacts doctors in the real world trying to make decisions on whether to prescribe a drug in several ways, Healy told the jury. For instance, he said, if he was doing his own writing, he “would write an article on the drug, warts and all.”
“But if the article has been written by a ghostwriter working for one of the pharmaceutical companies,” he said, “the chances are the warts are somehow going to vanish.”
“The article will talk about the good aspects of the drug and will leave out the risky issues which are probably the most important things for the practicing doctor to know,” he explained.
If the ghost author comes from an extremely distinguished university, doctors reading the article will think it has to be right, he said. “The simple fact that the article is going to be apparently written by this big named person and appears in an extremely good journal means that most average doctors will think this has to be true,” he told the jury.
It's not just the case of the doctor who reads the article being deceived, he said. “It's the fact that the credibility of the institution is and the name is being used to sell the drug, as well.“
Healy came face-to-face with ghostwriting when one of the drug companies offered to ghostwrite his articles, he said. Since then, he has researched the ghostwriting process to assess how common it is.
The assessment found that “at least half, maybe more, of the articles that appear in major journals under the names of the best known people in the field, are ghostwritten when they have to do with pharmaceutical drugs,” he told the jury.
“If they have to do with the drugs that are being sold at the moment, the ones that are fashionable at the moment, then these articles are highly likely to be ghostwritten even when they appear in the very best journals,” Healy said.
Ghostwriting Up Close
While testifying, Healy told the jury that he was familiar with companies that Glaxo hired to ghostwrite literature and put other doctors' names on it. “I think the leading firm in the field was one called STI,” he said. “This stands for Scientific Therapeutics Information.”
The jury was shown a July 28, 2003, document sent to the Glaxo product manager for Paxil, by Sally Laden, working for STI, which stated: “Thank you for offering me the chance to work with you to write two review articles.”
“This letter summarizes my fees for this project,” Laden wrote. “The safety paper is priced higher because of a greater number of named authors and the anticipated additional work involved in assessing the CR data in progress.”
For the development of the manuscript, and up to five drafts, the price quoted was $12,000. One of the topics for a manuscript was on the safety of antidepressants in breast-feeding.
“The first draft will be the first run through the material,” Healy told the jury. “She will have put the article together laying out the issues, laying out the references, structuring the paper up in the way that the journal she actually expects that this paper is going to go to will want the article structured.”
Draft 2 goes back to Glaxo again and the author, whoever is actually going to put their name on the paper. Then draft 3 goes back to Glaxo and the author for sign-off, and then there will be a final version that goes to the journal, Healy explained. Then draft 5 is revisions from journal reviewers, he said.
He noted that Laden said the safety paper is more expensive because there was going to be more authors. “I should emphasize that more authors here does not mean more authors writing the paper,” Healy told the jury. “It means more names appearing on the authorship line.”
“She has to recruit people and the people whose names are on the authorship line get paid for being authors,” he explained.
Sally Laden's “name has appeared on a range of different articles that have been produced for GlaxoSmithKline, not just on the issue of giving drugs to women of childbearing years but across the board,” Healy said.
During Healy's testimony, the family's lead attorney from Houston, Sean Tracey, introduced the actual manuscript by STI. “This is an article that is going to go to a journal,” Healy said. “It has been authored by Ms. Laden, contrary to what appears there.”
The names Zachary Stowe and Jeffrey Newport appeared on the authorship line. Healy noted that Draft 4 stated: “Final article cover page to be removed.”
“The cover page will be removed,” he explained, “because the journal will treat the article quite differently if they think that the true author is not on the authorship line.”
Healy said the paper was an example of ghostwriting. “It is going to go to a journal called Psychopharmacology Bulletin,” he testified. “And in this particular issue of the journal where this paper later comes out, every paper in that issue of the journal has to do with Paxil.”
The jury was then shown the actual article that was published and it was the exact same article but without Laden's name on it.
Healy testified that Stowe runs the women's mental health program at Emory University and publishes on SSRIs and women's health issues, with publications favorable to Paxil, and also gives seminars and talks for other doctors which outline “how it can be a good thing to treat women of childbearing years with Paxil.”
He was not allowed to tell the jury how much Glaxo had paid Stowe over the last year or two, which was revealed by an investigation led by Iowa Senator, Charles Grassley, as the ranking Republican on the US Senate Finance Committee. The amount Stowe got paid “is not public knowledge where you can show me a document that says it,” the judge said.
However, Stowe's Glaxo earnings are most certainly public knowledge. A google search in December 2009, with the following three key words in quotes, “Stowe” “GSK” “paid,” brought up 15,800 hits.
On June 10, 2009, in reference to Stowe, the Wall Street Journal reported, “Emory University has disciplined a prominent psychiatrist who was being paid by an antidepressant maker at the same time he was conducting federal research about the use of such drugs in pregnant women.”
The National Institute of Mental Health said “it is reviewing Stowe’s activities, prompted by a letter from a U.S. Senate committee that said Stowe received $253,700 in 2007 and 2008 for “essentially promotional talks” for the drug maker GlaxoSmithKline,” the June 11, 2009 Atlanta Journal-Constitution reported.
The charts with dates for Stowe's promotional talks reveal that many times he gave two talks for Glaxo on the same date and made five grand per day, in addition to payment for all traveling expenses. On one date, he billed $96 for meals alone.
For ready reference, the list of academics in the field of psychiatry identified by Grassley's investigation thus far, as not fully disclosing money from drug companies, includes Joseph Biederman, Thomas Spencer and Timothy Wilens at Harvard, Charles Nemeroff and Zackery Stowe from Emory; Melissa DelBello at the University of Cincinnati; Alan Schatzberg, president of the American Psychiatric Association, from Stanford; Martin Keller at Brown University; Karen Wagner and A John Rush from the University of Texas; and Fred Goodwin, the former host of the radio show, "Infinite Minds," broadcast for years by National Pubic Radio, before it was thrown off the air.
The supplement to the Spring 2003, “Psychopharmacology Bulletin,” found online, sure enough shows the ghostwritten paper, “Clinical Management of Perinatal Depression: Focus on Paroxetine,” with the names Stowe and Newport, along with papers by Martin Kelly, Charles Nemeroff, Alan Schatzberg, Karen Wagner, and Kim Yonkers, for a total of fourteen Paxil papers altogether.
Under “Disclosure,” the article ghostwritten by Laden stated: “This work was supported by an unrestricted educational grant from GlaxoSmithKline. Doctor Stowe serves as scientific advisor for and receives research grants from Pfizer and GlaxoSmithKline. He also receives grant support from Wyeth.”
The disclosure that the work was supported with a grant from Glaxo would not tell a doctor reading the paper that it was actually written by somebody else, Healy said.
While testifying, Healy explained that an “unrestricted educational grant, if I were to receive one, it would assume that I am saying things that are relatively favorable to the pharmaceutical company who has given me the educational grant.”
“If I am saying things hostile to the drug,” he said, “I will not get an unrestricted educational grant, although the word “unrestricted” suggests that I should.”
Stowe's undisclosed income above was from Glaxo alone. In August 2007, he was listed as an author on a study titled, “Atypical Antipsychotic Administration During Late Pregnancy,” in the American Journal of Psychiatry.
According to the disclosure section, Stowe has received research support from Glaxo, Pfizer, and Wyeth, has served on advisory boards for Glaxo, Wyeth, and Bristol-Myers Squibb, and has served on speaker’s bureaus and/or received honoraria from Glaxo, Lilly, Pfizer, and Wyeth.
The second author on the ghostwritten paper, Jeffrey Newport, is the associate director of Emory's Women’s Program. Newport was also an author on the “Atypical Antipsychotic” study. He has received research support from Glaxo, Lilly, Janssen, the National Alliance for Research on Schizophrenia and Depression, NIH, and Wyeth, and, he has served on speaker’s bureaus for Glaxo, AstraZeneca, Lilly, Pfizer, and Wyeth, according to the disclosures.
The next person the jury heard about was Charles Nemeroff. He was also an author on the atypical study. Nemeroff was the Chief of Psychiatry at Emory, until he lost the position last year, Healy told the jury. “He's possibly best known or was the best known psychiatrist in the United States.”
“He influenced an awful lot of heads of departments, professors of psychiatry, general people within the field of academic mental health, and through them and an awful lot of prescribing doctors here in the U.S. And, indeed, perhaps worldwide,” Healy testified.
A link to “Articles” on the Emory website in mid-2009, brought up roughly 90 studies and papers that include the co-author Nemeroff.
Healy said he believed Nemeroff was one of the founding members of the Paxil advisory board and he participated in continuing medical education seminars with talks on Paxil.
Nemeroff would have been “the key person in producing the kinds of talks with slides that would have been held for large audiences of doctors, and then those slides and talks would have been distributed out to different doctors in the field who hadn't been at the major meetings as he gave his talk,” Healy told the jury.
During his testimony, Tracey showed Healy a document from a continuing medical education seminar titled, “Fertility, Mood and Motherhood,” and Healy said the material for the seminar was prepared by Glaxo for Nemeroff. It was again supported by unrestricted educational grant from Glaxo and Nemeroff “was reimbursed for his role in this,” Healy pointed out.
Healy was also not allowed to testify about Nemeroff's fall from grace at Emory, how much he was paid by Glaxo, or his failure to disclose over a million dollars from drug companies.
Dr Bernard Carroll, a past chairman of the department of psychiatry at Duke University Medical Center, summarized the Nemeroff saga well on the Healthcare Renewal website on November 3, 2008, in writing: “The fallout to date includes his severance from several NIH-funded projects at Emory University School of Medicine, a freeze of NIH funding for a major center grant, and his stepping down from Emory’s chair of psychiatry while an internal investigation proceeds.”
During her cross examination of Healy, Glaxo's lead attorney, Chilton Varner, presented an exhibit showing a continuing medical education presentation given by Nemeroff.
“Can you see that in this continuing medical education program Doctor Nemeroff says that paroxetine, sertraline, fluvoxamine, (are) not associated with increased risk of teratogenicity or other complications?” she asked Healy.
“Yes, I do,” he replied.
In small print, the disclosure for the presentation showed Nemeroff had received research grants and participated in the speakers bureau and consulted for Glaxo, Eli Lilly, Solvay and Pfizer.
During re-direct, Tracey asked Healy to tell the jury what the actual results of the study that Nemeroff was discussing in the presentation showed, and specifically when Paxil was looked at alone. The results “showed that there was a 1.8-fold increase in the odds ratio of a birth defects to the women who have been taking Paxil during pregnancy,” Healy testified.
“Overall, for this group of drugs there was an increase in risk,” he said, “but specifically for Paxil the risk was greatly increased.”
“And beyond that,” Healy stated, “what isn't included here in the conclusions, overall there was a -- on this group of drugs, there was a doubling of the rate of miscarriages on the drug compared with the rate of miscarriage for the women who are being compared who weren't on the drug.”
“There was also an increased rate of women going on to voluntarily abortions on the drug,” he added.
One of the lead authors on the study was Gideon Koren. “Doctor, without giving any details,” Tracey asked Healy, “do you know whether Doctor Koren has ties to the pharmaceutical industry?”
“I know he has,” Healy said.
During his opening statement, Tracey told the jury that 1998 was a big year for Paxil because a study came out by a doctor named Gideon Koren, and a researcher named Kulin, that looked at Paxil and two other SSRIs.
The study compared women who took SSRIs, to women who didn't take any SSRIs, and the number of birth defects in the two groups was the same. “So Doctor Koren concluded that SSRIs appear to be safe,” Tracey said.
“Within, literally within 24 hours,” he told the jury, “GSK's marketing machine cranked up and they faxed this information to their entire sales force.”
And the sales force took this information and began to use it to sell to women, he noted. “What they didn't tell anybody was this,” Tracey said. “That when you separated Paxil out from the other SSRIs, you saw that Paxil was causing birth defects, that there was an increased risk of birth defects in this study in these women when you looked at Paxil by itself.”
“That was not in the paper,” he said. “That information was not found out until two years ago.”
While testifying, Healy was barred from telling the jury about Koren's involvement in one the biggest academic research scandals in history a few years back when he sent vicious anonymous letters to discredit fellow researchers and denied doing so until DNA evidence from postage stamps proved he was lying years later. In September 2003, the Canadian Association of University Teachers reported on the disciplining of Koren in the CAUT Bulletin as follows:
“The Ontario College of Physicians and Surgeons has formally reprimanded University of Toronto professor of medicine Dr. Gideon Koren. He had written anonymous harassing letters about Dr. Nancy Olivieri and three colleagues during Olivieri's dispute with the Hospital for Sick Children, the University of Toronto and Apotex Inc. He then had lied repeatedly to conceal his responsibility. The college also cited him for additional misconduct, in research.”
The Teachers Association further explained in the Bulletin: “The college's finding of research misconduct was in relation to a study on a drug to treat a blood disorder in children that Koren and Olivieri had once collaborated on. Olivieri identified risks that the drug was ineffective and caused liver damage, and voiced her concerns despite legal warnings from its maker, Apotex. Koren differed and, contrary to accepted norms, published an article on the drug using data from other researchers, including Olivieri, without their knowledge or consent.”
“Koren had received hundreds of thousands of dollars in funding from Apotex after the company had terminated the drug trials in its efforts to prevent Olivieri from disclosing risks to patients, as well as the hundreds of thousands of dollars in funding he had received during the trials,” the newsletter reported, citing an journal article by the authors of “The Olivieri Report.”
Apotex marketed a generic version of Paxil, or paroxetine.
The penalty had been jointly proposed to the discipline committee through prior agreement between Koren's attorney and counsel for the college, the Bulletin noted. In its decision, the committee said it was “deeply troubled by this case” and “seriously considered administering a more severe penalty” than that proposed, as it wished “to express unequivocally its condemnation of Dr. Koren's misconduct.”
Glaxo Money Still Flowing
In a December 14, 2009 report on Pharmalot, Ed Silverman noted that Glaxo had published a list of fees paid out to US healthcare professionals for speaking and consulting services for the three month period of April 1, 2009 to June 30, 2009. “By its own tally, Glaxo paid $14.6 million to approximately 3,700 US docs and other healthcare professionals,” he reported.
Although Glaxo paid out millions of dollars over the years to the doctors discussed in this article, not one of them was called to testify as an expert in the first birth defect trial.
(The Paxil Birth Defect Litigation Update Series is sponsored by the Houston law firm of Vickery, Waldner and Mallia at www.justiceseekers.com)
A month before the first Paxil birth defect trial against GlaxoSmithKline was set to begin, the Associated Press ran the headline, “Glaxo Used Ghostwriting Program to Promote Paxil,” in reporting on a program called “CASPPER,” which allowed doctors to “take credit for medical journal articles mainly written by company consultants.”
“Drug companies frequently hire outside firms to draft a manuscript touting a company's drug, retain a physician to sign off as the author and then find a publisher to unwittingly publish the work,” the Associated Press said on August 19, 2009. “Drug company salespeople often present medical journal articles to physicians as independent proof that their drugs are safe and effective.
Between 2000 and 2002, articles from the CASPPER program appeared in five medical journals. On August 21, 2009, Jim Edwards on BNET, described the CASSPER ghostwriting brochure. The document shows that the intent of CASSPER was to flood the market with ghostwritten information, he said. It stated: “Paxil Product Management has budgeted for 50 articles for 2000.”
The trial in Kilker v Glaxo ended on October 13, 2009, with a jury in Philadelphia finding that Glaxo “negligently failed to warn” the doctor treating Lyam Kilker's mother about Paxil’s risks and the drug was a “factual cause” of Lyam's heart defects. The family was award $2.5 million.
Ghostwriting 101
The world-renowned neuropsychopharmacologist from the UK, Dr David Healy, testified as an expert witness for the plaintiffs in the Kilker trial.
While testifying, Healy explained the process of ghostwriting to the jury. He said ghostwriting probably began seriously in the 1980s. “It's where an article appears under the name of usually a fairly distinguished person in the field,” he testified.
But it involves more than just the true author being concealed, he told the jury. “It's a process where the ghostwriters work for companies who are very good at getting articles into the best journals in the field, like the New England Journal of Medicine, and recruiting some of the best known names in the field to be the apparent authors of the articles.”
“They may come from one of the big named universities like Princeton or whoever, but the actual fact the person who appears to be the author isn't the true author,” he said. “If you were to read the article, you often don't get any hints of who the true author of the article actually was.”
Ghostwriting impacts doctors in the real world trying to make decisions on whether to prescribe a drug in several ways, Healy told the jury. For instance, he said, if he was doing his own writing, he “would write an article on the drug, warts and all.”
“But if the article has been written by a ghostwriter working for one of the pharmaceutical companies,” he said, “the chances are the warts are somehow going to vanish.”
“The article will talk about the good aspects of the drug and will leave out the risky issues which are probably the most important things for the practicing doctor to know,” he explained.
If the ghost author comes from an extremely distinguished university, doctors reading the article will think it has to be right, he said. “The simple fact that the article is going to be apparently written by this big named person and appears in an extremely good journal means that most average doctors will think this has to be true,” he told the jury.
It's not just the case of the doctor who reads the article being deceived, he said. “It's the fact that the credibility of the institution is and the name is being used to sell the drug, as well.“
Healy came face-to-face with ghostwriting when one of the drug companies offered to ghostwrite his articles, he said. Since then, he has researched the ghostwriting process to assess how common it is.
The assessment found that “at least half, maybe more, of the articles that appear in major journals under the names of the best known people in the field, are ghostwritten when they have to do with pharmaceutical drugs,” he told the jury.
“If they have to do with the drugs that are being sold at the moment, the ones that are fashionable at the moment, then these articles are highly likely to be ghostwritten even when they appear in the very best journals,” Healy said.
Ghostwriting Up Close
While testifying, Healy told the jury that he was familiar with companies that Glaxo hired to ghostwrite literature and put other doctors' names on it. “I think the leading firm in the field was one called STI,” he said. “This stands for Scientific Therapeutics Information.”
The jury was shown a July 28, 2003, document sent to the Glaxo product manager for Paxil, by Sally Laden, working for STI, which stated: “Thank you for offering me the chance to work with you to write two review articles.”
“This letter summarizes my fees for this project,” Laden wrote. “The safety paper is priced higher because of a greater number of named authors and the anticipated additional work involved in assessing the CR data in progress.”
For the development of the manuscript, and up to five drafts, the price quoted was $12,000. One of the topics for a manuscript was on the safety of antidepressants in breast-feeding.
“The first draft will be the first run through the material,” Healy told the jury. “She will have put the article together laying out the issues, laying out the references, structuring the paper up in the way that the journal she actually expects that this paper is going to go to will want the article structured.”
Draft 2 goes back to Glaxo again and the author, whoever is actually going to put their name on the paper. Then draft 3 goes back to Glaxo and the author for sign-off, and then there will be a final version that goes to the journal, Healy explained. Then draft 5 is revisions from journal reviewers, he said.
He noted that Laden said the safety paper is more expensive because there was going to be more authors. “I should emphasize that more authors here does not mean more authors writing the paper,” Healy told the jury. “It means more names appearing on the authorship line.”
“She has to recruit people and the people whose names are on the authorship line get paid for being authors,” he explained.
Sally Laden's “name has appeared on a range of different articles that have been produced for GlaxoSmithKline, not just on the issue of giving drugs to women of childbearing years but across the board,” Healy said.
During Healy's testimony, the family's lead attorney from Houston, Sean Tracey, introduced the actual manuscript by STI. “This is an article that is going to go to a journal,” Healy said. “It has been authored by Ms. Laden, contrary to what appears there.”
The names Zachary Stowe and Jeffrey Newport appeared on the authorship line. Healy noted that Draft 4 stated: “Final article cover page to be removed.”
“The cover page will be removed,” he explained, “because the journal will treat the article quite differently if they think that the true author is not on the authorship line.”
Healy said the paper was an example of ghostwriting. “It is going to go to a journal called Psychopharmacology Bulletin,” he testified. “And in this particular issue of the journal where this paper later comes out, every paper in that issue of the journal has to do with Paxil.”
The jury was then shown the actual article that was published and it was the exact same article but without Laden's name on it.
Healy testified that Stowe runs the women's mental health program at Emory University and publishes on SSRIs and women's health issues, with publications favorable to Paxil, and also gives seminars and talks for other doctors which outline “how it can be a good thing to treat women of childbearing years with Paxil.”
He was not allowed to tell the jury how much Glaxo had paid Stowe over the last year or two, which was revealed by an investigation led by Iowa Senator, Charles Grassley, as the ranking Republican on the US Senate Finance Committee. The amount Stowe got paid “is not public knowledge where you can show me a document that says it,” the judge said.
However, Stowe's Glaxo earnings are most certainly public knowledge. A google search in December 2009, with the following three key words in quotes, “Stowe” “GSK” “paid,” brought up 15,800 hits.
On June 10, 2009, in reference to Stowe, the Wall Street Journal reported, “Emory University has disciplined a prominent psychiatrist who was being paid by an antidepressant maker at the same time he was conducting federal research about the use of such drugs in pregnant women.”
The National Institute of Mental Health said “it is reviewing Stowe’s activities, prompted by a letter from a U.S. Senate committee that said Stowe received $253,700 in 2007 and 2008 for “essentially promotional talks” for the drug maker GlaxoSmithKline,” the June 11, 2009 Atlanta Journal-Constitution reported.
The charts with dates for Stowe's promotional talks reveal that many times he gave two talks for Glaxo on the same date and made five grand per day, in addition to payment for all traveling expenses. On one date, he billed $96 for meals alone.
For ready reference, the list of academics in the field of psychiatry identified by Grassley's investigation thus far, as not fully disclosing money from drug companies, includes Joseph Biederman, Thomas Spencer and Timothy Wilens at Harvard, Charles Nemeroff and Zackery Stowe from Emory; Melissa DelBello at the University of Cincinnati; Alan Schatzberg, president of the American Psychiatric Association, from Stanford; Martin Keller at Brown University; Karen Wagner and A John Rush from the University of Texas; and Fred Goodwin, the former host of the radio show, "Infinite Minds," broadcast for years by National Pubic Radio, before it was thrown off the air.
The supplement to the Spring 2003, “Psychopharmacology Bulletin,” found online, sure enough shows the ghostwritten paper, “Clinical Management of Perinatal Depression: Focus on Paroxetine,” with the names Stowe and Newport, along with papers by Martin Kelly, Charles Nemeroff, Alan Schatzberg, Karen Wagner, and Kim Yonkers, for a total of fourteen Paxil papers altogether.
Under “Disclosure,” the article ghostwritten by Laden stated: “This work was supported by an unrestricted educational grant from GlaxoSmithKline. Doctor Stowe serves as scientific advisor for and receives research grants from Pfizer and GlaxoSmithKline. He also receives grant support from Wyeth.”
The disclosure that the work was supported with a grant from Glaxo would not tell a doctor reading the paper that it was actually written by somebody else, Healy said.
While testifying, Healy explained that an “unrestricted educational grant, if I were to receive one, it would assume that I am saying things that are relatively favorable to the pharmaceutical company who has given me the educational grant.”
“If I am saying things hostile to the drug,” he said, “I will not get an unrestricted educational grant, although the word “unrestricted” suggests that I should.”
Stowe's undisclosed income above was from Glaxo alone. In August 2007, he was listed as an author on a study titled, “Atypical Antipsychotic Administration During Late Pregnancy,” in the American Journal of Psychiatry.
According to the disclosure section, Stowe has received research support from Glaxo, Pfizer, and Wyeth, has served on advisory boards for Glaxo, Wyeth, and Bristol-Myers Squibb, and has served on speaker’s bureaus and/or received honoraria from Glaxo, Lilly, Pfizer, and Wyeth.
The second author on the ghostwritten paper, Jeffrey Newport, is the associate director of Emory's Women’s Program. Newport was also an author on the “Atypical Antipsychotic” study. He has received research support from Glaxo, Lilly, Janssen, the National Alliance for Research on Schizophrenia and Depression, NIH, and Wyeth, and, he has served on speaker’s bureaus for Glaxo, AstraZeneca, Lilly, Pfizer, and Wyeth, according to the disclosures.
The next person the jury heard about was Charles Nemeroff. He was also an author on the atypical study. Nemeroff was the Chief of Psychiatry at Emory, until he lost the position last year, Healy told the jury. “He's possibly best known or was the best known psychiatrist in the United States.”
“He influenced an awful lot of heads of departments, professors of psychiatry, general people within the field of academic mental health, and through them and an awful lot of prescribing doctors here in the U.S. And, indeed, perhaps worldwide,” Healy testified.
A link to “Articles” on the Emory website in mid-2009, brought up roughly 90 studies and papers that include the co-author Nemeroff.
Healy said he believed Nemeroff was one of the founding members of the Paxil advisory board and he participated in continuing medical education seminars with talks on Paxil.
Nemeroff would have been “the key person in producing the kinds of talks with slides that would have been held for large audiences of doctors, and then those slides and talks would have been distributed out to different doctors in the field who hadn't been at the major meetings as he gave his talk,” Healy told the jury.
During his testimony, Tracey showed Healy a document from a continuing medical education seminar titled, “Fertility, Mood and Motherhood,” and Healy said the material for the seminar was prepared by Glaxo for Nemeroff. It was again supported by unrestricted educational grant from Glaxo and Nemeroff “was reimbursed for his role in this,” Healy pointed out.
Healy was also not allowed to testify about Nemeroff's fall from grace at Emory, how much he was paid by Glaxo, or his failure to disclose over a million dollars from drug companies.
Dr Bernard Carroll, a past chairman of the department of psychiatry at Duke University Medical Center, summarized the Nemeroff saga well on the Healthcare Renewal website on November 3, 2008, in writing: “The fallout to date includes his severance from several NIH-funded projects at Emory University School of Medicine, a freeze of NIH funding for a major center grant, and his stepping down from Emory’s chair of psychiatry while an internal investigation proceeds.”
During her cross examination of Healy, Glaxo's lead attorney, Chilton Varner, presented an exhibit showing a continuing medical education presentation given by Nemeroff.
“Can you see that in this continuing medical education program Doctor Nemeroff says that paroxetine, sertraline, fluvoxamine, (are) not associated with increased risk of teratogenicity or other complications?” she asked Healy.
“Yes, I do,” he replied.
In small print, the disclosure for the presentation showed Nemeroff had received research grants and participated in the speakers bureau and consulted for Glaxo, Eli Lilly, Solvay and Pfizer.
During re-direct, Tracey asked Healy to tell the jury what the actual results of the study that Nemeroff was discussing in the presentation showed, and specifically when Paxil was looked at alone. The results “showed that there was a 1.8-fold increase in the odds ratio of a birth defects to the women who have been taking Paxil during pregnancy,” Healy testified.
“Overall, for this group of drugs there was an increase in risk,” he said, “but specifically for Paxil the risk was greatly increased.”
“And beyond that,” Healy stated, “what isn't included here in the conclusions, overall there was a -- on this group of drugs, there was a doubling of the rate of miscarriages on the drug compared with the rate of miscarriage for the women who are being compared who weren't on the drug.”
“There was also an increased rate of women going on to voluntarily abortions on the drug,” he added.
One of the lead authors on the study was Gideon Koren. “Doctor, without giving any details,” Tracey asked Healy, “do you know whether Doctor Koren has ties to the pharmaceutical industry?”
“I know he has,” Healy said.
During his opening statement, Tracey told the jury that 1998 was a big year for Paxil because a study came out by a doctor named Gideon Koren, and a researcher named Kulin, that looked at Paxil and two other SSRIs.
The study compared women who took SSRIs, to women who didn't take any SSRIs, and the number of birth defects in the two groups was the same. “So Doctor Koren concluded that SSRIs appear to be safe,” Tracey said.
“Within, literally within 24 hours,” he told the jury, “GSK's marketing machine cranked up and they faxed this information to their entire sales force.”
And the sales force took this information and began to use it to sell to women, he noted. “What they didn't tell anybody was this,” Tracey said. “That when you separated Paxil out from the other SSRIs, you saw that Paxil was causing birth defects, that there was an increased risk of birth defects in this study in these women when you looked at Paxil by itself.”
“That was not in the paper,” he said. “That information was not found out until two years ago.”
While testifying, Healy was barred from telling the jury about Koren's involvement in one the biggest academic research scandals in history a few years back when he sent vicious anonymous letters to discredit fellow researchers and denied doing so until DNA evidence from postage stamps proved he was lying years later. In September 2003, the Canadian Association of University Teachers reported on the disciplining of Koren in the CAUT Bulletin as follows:
“The Ontario College of Physicians and Surgeons has formally reprimanded University of Toronto professor of medicine Dr. Gideon Koren. He had written anonymous harassing letters about Dr. Nancy Olivieri and three colleagues during Olivieri's dispute with the Hospital for Sick Children, the University of Toronto and Apotex Inc. He then had lied repeatedly to conceal his responsibility. The college also cited him for additional misconduct, in research.”
The Teachers Association further explained in the Bulletin: “The college's finding of research misconduct was in relation to a study on a drug to treat a blood disorder in children that Koren and Olivieri had once collaborated on. Olivieri identified risks that the drug was ineffective and caused liver damage, and voiced her concerns despite legal warnings from its maker, Apotex. Koren differed and, contrary to accepted norms, published an article on the drug using data from other researchers, including Olivieri, without their knowledge or consent.”
“Koren had received hundreds of thousands of dollars in funding from Apotex after the company had terminated the drug trials in its efforts to prevent Olivieri from disclosing risks to patients, as well as the hundreds of thousands of dollars in funding he had received during the trials,” the newsletter reported, citing an journal article by the authors of “The Olivieri Report.”
Apotex marketed a generic version of Paxil, or paroxetine.
The penalty had been jointly proposed to the discipline committee through prior agreement between Koren's attorney and counsel for the college, the Bulletin noted. In its decision, the committee said it was “deeply troubled by this case” and “seriously considered administering a more severe penalty” than that proposed, as it wished “to express unequivocally its condemnation of Dr. Koren's misconduct.”
Glaxo Money Still Flowing
In a December 14, 2009 report on Pharmalot, Ed Silverman noted that Glaxo had published a list of fees paid out to US healthcare professionals for speaking and consulting services for the three month period of April 1, 2009 to June 30, 2009. “By its own tally, Glaxo paid $14.6 million to approximately 3,700 US docs and other healthcare professionals,” he reported.
Although Glaxo paid out millions of dollars over the years to the doctors discussed in this article, not one of them was called to testify as an expert in the first birth defect trial.
(The Paxil Birth Defect Litigation Update Series is sponsored by the Houston law firm of Vickery, Waldner and Mallia at www.justiceseekers.com)
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