Last May, a Peabody was awarded to the film Depression: Out of the Shadows, a documentary which aired in 2008 on PBS, was produced by Twin Cities Public Television and WGBH Boston, and was written and directed by Minneapolis-based filmmaker Larkin McPhee.
The documentary profiled a wide variety of patients struggling with depression, including a former gang member from the California Bay Area, a new mother from Minneapolis, and Andrew Solomon, best selling author of The Noonday Demon, a depression memoir. As the diversity of McPhee’s subjects and the emotional honesty rendered in her patient interviews made apparent, depression is socially and economically indiscriminate in its capacity to cripple the human spirit.
But where her film was generous in its inclusion of heartbreaking personal stories about depression, its broad survey of the science of the illness included frequent appearances by Charles Nemeroff, M.D., a leading—some say powerful—mood disorders researcher from Emory University. Last fall, Nemeroff also became one of the most prominent psychiatrists to be rebuked for failing to disclose funds earned from the drug industry.
Last October, Senator Charles Grassley of Iowa notified Emory that Nemeroff had received $2.8 million from drug companies between 2000 and 2007, $1.2 million of which he failed to report to the university, as he was required to do according to federal rules. To reduce their risk of bias, National Institutes of Health (NIH) researchers must limit to $10,000 their annual receipt of payments from the makers of drugs they are studying. As the lead investigator for a five-year, $3.95 million federal grant to study Paxil and other GlaxoSmithKline drugs, Nemeroff pocketed seventeen times the NIH limit from GSK in 2004 alone, and exceeded his limit every year from 2003 through 2006, without informing his employers. Following his rebuke, Nemeroff lost his chairmanship at Emory, saw $9.2 million in NIH funds meant for Emory frozen, and was banned from federal research for two years.
Some might argue that little about this episode matters, since Nemeroff’s downfall took place in October and Depression: Out of the Shadows aired five months earlier. Yet a simple Google search would have alerted McPhee to the fact that Nemeroff, though the author of hundreds of research papers and well respected in his field, has been dogged by conflict of interest allegations for years. In 2003, he came under fire for praising three pharmaceutical products in the journal Nature Neuroscience without disclosing he held a financial stake in their success, one of which he held the patent on.
Three years later, Nemeroff resigned from his editorship of the journal Neuropsychopharmacology after The Wall Street Journal reported he held an undisclosed financial stake in a treatment for depression he praised in an article. Nemeroff is either great at making excuses for his conduct or extremely unlucky. Following his 2003 misstep, he blamed the journal in question for not requiring him to mention his conflicts. Following his omission in 2006, Nemeroff blamed a clerical error. Following his rebuke by Sen. Grassley, Nemeroff told his employers he did not realize that drug-industry sponsored continuing education appearances were payments requiring disclosure.
All defenses aside, by the time of production for Depression: Out of the Shadows, his drug industry entanglements were both widely distributed and widely known. “With financial ties to nearly two dozen drug and biotech companies,” wroteShannon Brownlee in The Washington Monthly in 2004, “Dr. Charles B. Nemeroff may hold some sort of record among academic clinicians for the most conflicts of interest.”
That PBS producers either did not know about Nemeroff’s drug industry entanglements or did not believe they tainted his discussion of the science of depression is disappointing. Indeed, the science of the illness and antidepressant medications is far less uniformly agreed upon than is depicted in the documentary. Disputes are ongoing over the efficacy, mechanism of action, and “targeted” nature of antidepressants—blockbuster drugs that remain the recipient of favorable press coverage even while now going off patent.
But what made the praise bestowed on this PBS documentary particularly troubling were the erroneous, drug-industry serving statements made by Nemeroff within the film—statements which had the potential to negatively affect public health, and which the documentary left unchallenged. During a segment on the FDA’s 2004 decision to require “black box” safety warnings stating that antidepressants can increase the risk of suicide in children and teenagers, a risk it extended in May of 2007 to users under twenty-five, Nemeroff seized the occasion to claim that the federal safety warning was mistaken.
He did so by citing a 2007 study partially funded by Pfizer and published in The American Journal of Psychiatry, a paper ostensibly linking the warning with a subsequent increase in teen suicides. “The FDA put a black box warning for all age groups,” Nemeroff said in the documentary. “I believe this was a mistake, because in hastening our awareness, what we’ve shown is there’s been a marked drop in prescriptions of antidepressants, particularly for children and adolescents…and an increase in suicides and suicide attempts.”
But as critics quickly pointed out
to The Boston Globe and The New York Times, the increase in suicides Nemeroff described actually occurred a year before a drop-off in antidepressant use. (You can’t blame a rise in suicides in 2003 on a drop off in prescriptions in 2005.) At the time, most parties to this debate agreed that the question of whether black-box warnings were inadvertently dangerous would not be further clarified until the release of Centers for Disease Control suicide data from 2005.
That data came out a month later, and showed that suicides have fallen overall; a follow-up report showed that suicides have fallen among youth specifically. The total number remains higher than in 2003, but less than in 2004, when the FDA warning went into effect.
Given the complexity of epidemiological data and the rarity of suicide, those findings prove little except that any effort to link an uptick in suicides to reduced prescribing of antidepressant medications to children and teenagers is not supported by the epidemiological data.
Something about the simultaneously complex and sympathetic nature of mental health reporting is making reputable journalistic organizations and well-meaning reporters sloppy. Last year, NPR aired a documentary on antidepressants and suicide in a radio show called The Infinite Mind. The show featured the comments of experts with undisclosed ties to the drug industry. This alone drew the wrath of observers—yet, as chronicled by Jonathan Leo, Ph.D on the Web site Chemicalimbalance.org, the documentary was peppered with inaccurate statements and drug-industry-serving spin. Its host, the psychiatrist Frederick Goodwin, eventually came under fire for not disclosing his own history of receiving money from the drug industry.
As the cases of PBS and NPR make clear, reporters who hand over their microphones to clinicians harboring such conflicts are the health beat equivalent of Judith Miller handing over her discussion of WMDs to Ahmed Chalabi. “I will not believe anything he says,” a Nemeroff critic and fellow psychiatrist told the Atlanta Journal Constitution following his downfall. “I will not believe anything he writes.”
If a source has critics like this, and if the judges for the Peabody Awards—or reporters they praise—cannot locate these critics, we deserve better awards.
Reminds me of the fact that PBS Frontline also pre-censored their documentary on U.S. health reform to exclude single payer and include over-reliance on insurance company spokepersons, and in effect fired its lead reporter, because he would not go along.
#1 Posted by Dr.steveB, CJR on Thu 25 Jun 2009 at 12:42 PM
I wouldn't defend Nemeroff. But you don't offer a remedy. Should journals refuse to publish studies by Nemeroff and the like?
Psychiatric research is notoriously underfunded. The National Institute of Mental Health does a handful of expensive, important studies, but the overwhelming majority of studies are paid for by drug companies. Virtually all psychiatrist researchers take money from drug companies because it is the only money available.
Our choice, sadly, is largely between drug-company-linked research, and no research. As someone who's written about personal experiences with mental illness in the family, I'll take any research over none.
The solution is vastly more government funding for psychiatric research. A trillion-dollars stimulus bill for mental health research could arguably do much more for the country than a bailout of the banks. But I don't expect that view to prevail.
In the meantime, I'll take drug-company-funded studies.
And you're wrong about one thing: Antidepressants have now been proven to work. They have side-effects, as all drugs do, but they are far superior to what preceded them: millions of people getting no treatment at all.
#2 Posted by Paul Raeburn, CJR on Fri 26 Jun 2009 at 09:25 AM
Just to clarify, the efficacy problems with antidepressants as mentioned are in relation to placebo upon meta analysis. (see link.)
#3 Posted by Paul Scott, CJR on Fri 26 Jun 2009 at 10:37 PM
Re: Reprimanded Psychiatrist? Bad Advice?
I just saw this article, or else I would have commented sooner. I am writing as the president of the company that produced The Infinite Mind, for a decade public radio’s most honored and listened to health and science program, which was referenced in the article.
As with previous articles on the topic of the media and medical researchers funded by pharmaceutical companies, including those published in CJR, there are several issues that are intertwined here and presented out of context.
First, there is no question that Emory’s Dr. Charles Nemeroff, along with the two other high-profile psychiatric researchers, Harvard’s Dr. Joesph Biederman and Dr. Fred Goodwin, the former host of public radio’s The Infinite Mind, should have disclosed the funding they received from drug companies, particularly the fees they were paid to give marketing talks to other doctors. In the case of Nemeroff and Biedeman, they were required to disclose those fees by federal and university rules, and in the case of Goodwin he was required to disclose his fees by his contractual agreement with his producers, and his responsibility as a journalist. I can’t speak for Harvard or Emory, but as Goodwin’s employer, there is no question that he could not, and would not, have continued as the host of the public radio program if his pharmaceutical fees were known.
With regard to the PBS documentary on depression, cited in your article, in retrospect, knowing what is known today, the inclusion of Nemeroff in the documentary appears to have been a bad choice. But hindsight is 20/20. The more important journalism questions are 1) when should the conflicts of interest of experts be disclosed?; and 2) does accepting pharmaceutical funding for research or speaking permanently taint a researcher from being able to comment on a medical topic? Or taint the results of that research? Consider that, as you noted, "The Infinite Mind" was attacked by Slate.com in May 2008 for its "Prozac Nation: Revisited" program. At the heart of Slate’s attack was that 1) The Infinite Mind had not mentioned that guest Dr. Nada Stotland, the president of the American Psychiatric Association, had at one point been paid to give talks for pharmaceutical companies; 2) we did not mention that a leading UCLA researcher, Dr. Andrew Leuchtner, had received pharmaceutical funding for research separate from the topic being discussed in the program; and 3) we failed to disclose that former FDA official Peter Pitts (who was on the program due to his involvement with topic of the show, the FDA black box warning on anti-depressants, and as head of the non-profit Center for Medicine in the Public Interest) had also worked as a PR person for pharmaceutical companies, a fact that we were not aware of, nor was NPR or PBS' Newshour, who had Pitts on the air, without disclosing his pharmaceutical ties. Slate singled out The Infinite Mind for criticism regarding these disclosures, knowing that the public radio show had followed the same practice as other news organizations, from NPR to the New York Times to CNN, regarding disclosure of pharmaceutical funding (for example, Dr. Nada Stoland had just previously been on CNN, with no reference to her pharmaceutical funding from years before.)
Clearly, there needs to be full disclosure when there is direct conflict of interest, but when, where and how it is required when dealing with pharmaceutical companies is less clear. This is an evolving area, which needs more discussion and professional guidelines. But simply to say that a piece of reporting is rotten because it failed to report that an interviewee or guest on a broadcast once received funds from a pharmaceutical company, for research or even speaking fees, is shortsighted. Furthermore, to put a label on every researcher who has accepted pharmaceutical funding, without providing context, does the reader/vi
#4 Posted by Bill Lichtenstein, CJR on Mon 14 Sep 2009 at 08:35 AM
Wow. Where do I start. The issue of whether or not the SSRIs lead to an increased rate of suicides is not a trivial matter and the subject deserves a full and open hearing. The major theme of my essay about the Infinite Mind's presentation of the topic was that it was extremely one-sided and that it did not present both sides of the debate. I believe I wrote a very careful critique of the show, and I pointed out very specific errors of fact. I tried to show that people and organizations, like the FDA, who see a potential problem have formed their opinion because of the data. I have tried several times to get Mr. Lichtenstein to address the issues I pointed out but he has not done so. At the very least, if I am wrong shouldn't I be easy to rebut? For instance, I pointed out that since there is a major controversy over the black box warnings, which he now acknowledges in his statement above, then why didnt he have someone on the show to present the other side, like the FDA? Does that seem outlandish? One of the suggestions I made was for him to redo the show and have someone who could present the other side, like the FDA, for instance. Yet, rather than answer a single one of my critiques he has simply delved into ad hominem zingers. He feels that anyone who questions the FDA's black box warning has been fueled by misinformation and emotion. Since he has said my essay was part and parcel of this misinformation about the SSRIs I believe the ball is now in his court. He should let me and his readers know what was wrong in it. If there is something wrong with my essay I will be the first to correct it - something which NPR apparently does not do. -Jon Leo
#5 Posted by Jonathan leo, CJR on Thu 5 Nov 2009 at 03:57 PM
I am hesitant to address Bill Lichtenstein's comment, which I just now saw, but if I read him correctly, he is replyng to a straw man argument -- the idea that undisclosed drug funding automatically renders a source unreliable. (Though I must say that would be a reasonable standard.)The point he seems not to acknowledge about Nemeroff is that the Dr. had been featured in the press on two earlier occasions for conflicts of interest (see links) prior to the time period in which this piece would have been reported. Nothing "20/20 hindsight"about that.
Moreover, the CJR article I wrote took pains to stress that Nemeroff's appearance in the documentary was not merely accompanied by the COI, but that it appears that he advanced an inaccurate -- not "controversial" -- drug-industry serving argument about black box warnings. In short, the study he cited does not appear to support the claim being made about it. (My sense is that Nemeroff would have believed what he did about the drugs with or without the funding, incidentally. I have no doubt he genuinely cares about treating people with depression and like any good clinician, thinks he knows the best way to do so. But it is easy to sense after a following this issue while that the best researchers can get trapped in a bubble and only see the studies that support their position, Black Box-damning studies included.) You do not give details on the study you mention, so I have no way of telling whether it is meaningful or more of the same as the study cited by Nemeroff.
Did my article make the best case for the idea that drug warnings might increase suicides? No. I will just state in my defense that this article was a response to award having been given to a one-sided view of an issue -- I felt I had the right to assume that Nemeroff had made the best case for the other side. As I saw it, you have a highly conflicted source (Nemeroff) making an unsupported claim about an FDA safety warning -- the bar should be rather high for casting doubt on a safety warning -- with no rebuttal. My article was that rebuttal.
Lastly, I really must point out to that you are doing a discredit to the issue in trying to wave off Dr. Leo as "controversial." (Disclosure, I knew him casually back in college -- 25 years ago, and I speak with him on occasion as a source; he notified me of this post, but my reply here is my initiative alone.) Your reading of the DeAngelis comment calling him a "nobody and a nothing" for instance, suggests you appear not understand that episode very well. That comment made headlines because it reflected poorly on JAMA, not Leo, and embarrassed the journal. "Critics have challenged his research" also seems rather meaningless, to me anyway; critics have challenged everything. The question should be, does a critic's analysis make sense or not? Finally, Leo is hardly the only source alleging that the calls for Black Box warning repeal are frequently driven by spin. He is just the one I selected.
I will agree with Lichtenstein that reporting about mental illness amidst this adversarial and money-fueled research environment is not easy and not for the faint of heart. It is probably why the reporting is so frequently driven by pack-mentality. I have no doubt that everyone means well, and I said as much in this piece. I hope he will find room in his next documentary on this subject for voices outside of those normally allowed in.
#6 Posted by Paul Scott, CJR on Fri 6 Nov 2009 at 11:07 AM
I was very glad to come upon this discussion of bias in the field of psychology.
I support the notion that anyone once paid by a pharmaceutical company to hawk their products or the theories which support their use is tainted with an unresolvable conflict of interest, especially when disclosure is not forthcoming. Non-disclosure is not an oversight...it is a choice calculated to avoid a possible loss of credibility, because no matter how much a scientist, researcher, or physician wants to believe in their objectivity, they are in denial if they believe that they are not swayed by a paycheck.
There is a deeper question here, however One issue which is not introduced often enough is the fundamental bias towards accepting the use of pharmaceuticals to treat psychological distress in the first place. As a clinical psychologist and researcher, I know from experience that there is no therapeutic reason to rely on dangererous and ineffective drugs when approaches exist which are successful even with extreme cases of depression,anxiety, and even psychosis. Therefore, my opinion is that anyone willing to profit from their relationship with a pharmaceutical company is either ignorant or uncaring of the damage they are causing to both practitioners and clients in the field.
P.S. If this notion is new to anyone, please visit my website and blog at fullspectrumcenter.org/blog for more information.
#7 Posted by Dr. Alexander Bingham, CJR on Sun 11 Apr 2010 at 01:11 PM