My father got his M.D. in 1930; I got mine in 1958. Insulin and penicillin came into being during his early years of practice. In my first years as a psychiatrist, tranquilizers and antidepressants changed the landscape of mental health. As doctors, Dad and I both welcomed Medicare in 1965; later on as patients we became grateful beneficiaries.
I remember him explaining “ethical pharmaceuticals” — a term that distinguished companies like Merck from hucksters of “patent medicines.” The scandal at Merck about the arthritis drug Vioxx came after his time — he would have been appalled.
Recently the line between ethical drug companies and hucksters was blurred by GlaxoSmithKline, which paid a record fine for its bad acts. Until this Glaxo case, drug firms took fines and some bad publicity in stride as a cost of business; now the companies and Wall Street are getting a new message.
Medicine is a profession — a calling, not a business. In Dad’s lifetime it was unethical for doctors, hospitals and pharmaceutical companies to advertise. Now it is legal, and presumably ethical, to peddle prescription drugs to patients who get doctors to swing at the advertiser’s pitch. Doctors earn much more for prescribing, testing and treating than for explaining. Insurance pays for the expensive drug. How many doctors will take the time to suggest a cheaper generic drug with an excellent track record?
Direct-to-consumer (DTC) advertising is legal in only two countries, the U.S. and New Zealand. It’s a very profitable exercise of free speech for commercial broadcasters that lease our public airwaves.
Although most doctors oppose DTC advertising, medical associations are no match for the combined force of Big Pharma and the TV networks. Drug companies spend far more on marketing than on research. Profits come mainly from new drugs under patent, only some of which have been proved better than less expensive, well-tested generic drugs.
The Food and Drug Administration has been a muffled watchdog, where political pressure for new drugs could trump research. Enormous quantities of psychiatric drugs — chiefly antidepressants and antipsychotics — flow through the blood streams of Americans; the residues are measurable in municipal effluent waterways. Psychiatrists are only four percent of physicians, so most psychiatric drugs are prescribed by nonspecialists. The “depression hurts” ads that say “ask your doctor” do not mean your psychiatrist!
Medicare, a huge benefit to older Americans, has been effective partly because of its nonprofit single-payer system. Unfortunately, the program suffers from too little government regulation. Prescriptions are paid for with little or no attention to comparative efficacy, safety, and cost. Unlike the Veterans Administration, Medicare cannot negotiate lower drug prices. Elderly patients are routinely overmedicated, and too often hospitalized when home care is preferable.
Private health insurance is stricter than Medicare in some ways, but not with pharmaceuticals. Despite cautionary teaching in medical schools, rampant overprescription of antibiotics has created monsters — resistant bacteria that threaten us in everything from hospitals to handshakes. With its airwaves full of prescription drug ads, our government must protect citizens against half-truths masquerading as health education.
The new ED, formerly “impotence,” was created by corporate greed, not medical need. Most of the over 20 million men (according to ads) who’ve asked their doctors about sexual insufficiency have a psychological or relationship problem.
The vast majority of doctors prescribing ED drugs are neither psychiatrists nor urologists: they have little time, interest — even training — for a good sexual history. They should, but won’t, interview the patient with his partner — a basic diagnostic step. For a few patients with organic disease the drug is a worthwhile treatment; for most it’s a permanent crutch, a costly and possibly unhealthy drug dependence.
The American Psychiatric Association (APA) has done little to help. Psychiatrists don’t want to criticize other physicians, and the APA itself depends on drug ads for its periodicals. Clinical psychologists and marital therapists who do not prescribe drugs are better equipped for couples work than psychiatrists, who earn much more for three medication sessions an hour than for one session of talk therapy. Of course, there are no ads for psychotherapy or marriage counseling.
Americans have a weakness for the pill, the quick fix. Patent medicine makers are happy to habituate them. The obligatory list of awful side effects seems to be no deterrent. ED is a special case, at a time when Internet porn has become increasingly obscene in order to produce the excitement that readers once got from a D. H. Lawrence novel.
These days a curious child can only wonder about an erection that lasts more than four hours, and concerned adolescents might wonder about how long they have before ED sets in. Pharmaceutical and network executives are parents and grandparents, too. How would they answer these questions?