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Therapy vs. Medication, Conflicts of Interest, and Intimidation

What started as an academic dispute regarding disclosure of conflict of interest is now snowballing into the mainstream media, due to the over-reaction by JAMA editors as reported in this Wall Street Journal blog post, JAMA editor calls Critic a “Nobody and a Nothing

In summary, Dr. Jonathan Leo, the “Critic”, dared to draw attention to 2 important points regarding a study comparing the efficacy of therapy vs. medication published in the Journal of the American Academy of Medicine (JAMA) – one of the most prestigious scientific publications:

1) The study results were presented and reported in a biased way, since they favored one specific intervention, a drug, while ignoring another one, therapy-based, that had equally statistically significant effects.

2) Both the lead author of the study and one of the main experts asked to comment on the study in several media outlets had undisclosed and unreported conflicts of interest. JAMA could have done a 5-minute Google search to identify and report the conflict of interest of the lead author (received a variety of revenues from the drugmaker).

Dr. Leo has summarized the continuing matter in several impressive letters. The 2 main ones, in chronological order:

Clinical Trials of Therapy vs. Medication: Even in a Tie, Medication Wins(BMJ)

– “Central to the idea of evidence-based medicine is that the choices made by patients and doctors to use a certain treatment should at least in part be based on scientific studies published in peer reviewed academic journals. For a patient diagnosed with a mental disorder, the choice often comes down to whether to use behavioral therapy, psychotropic medications, or a combination of the two. We think the following story will shed some light on how conflicts of interest can complicate the decision making process.”

– “Fox News interviewed an expert psychiatrist from the University of Pittsburgh and reported that, “he hopes doctors will start prescribing preventive antidepressants to stroke patients.” The expert said nothing about therapy

– “Five months later, our letter was published along with an acknowledgement from the original authors that indeed the difference between therapy and medication was not statistically significant. Since newspapers rarely reflect on their original coverage, the benefits of therapy for stroke patients will continue to remain a mystery to most of the news reading public.”

JAMA editors,including Catherine DeAngelis, editor-in-chief of JAMA, then reacted in a way that can best be described as public intimidation via explicit and veiled threats to Dr. Leo AND his university.

You can read Dr. Leo’s response at the link below.

Academic Freedom and Controversy Over the Publication of Factually Correct, Publicly Available Information

– “The implications of the JAMA’s reaction to our letter are significant. For instance, the pharmaceutical industry is often criticized for their impact on evidence-based medicine. In the past, I have criticized direct-to-consumer advertising of psychiatric medications, which is not helpful to Big Pharma. However, I have never been telephoned or threatened by representatives from Big Pharma. In contrast to my experience with JAMA, any exchanges have been civil and appropriate.”

You can read a complete narrative of the affair here: Catherine DeAngelis and JAMA: What is going on here?

The big challenge here is, of course, to discern how different tools, such as drugs and therapy, can be best used, either on their own or in combination.

Update (03/30): The American Medical  Association has announced a probe of JAMA editors’ actions. We will keep you informed.

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3 Responses

  1. Thank you for the excellent overview of this issue. As a physician I knew that the JAMA editor was whining about something, but I had not taken the time to check the story out.

    This story certainly emphasizing the on-going problem of apparent publication bias in favor of pharmaceutical solutions to all medical problems.

  2. Alvaro says:

    Hello Ginger,

    JAMA’s reaction is being more surreal and dissapointing than reassuring, and perhaps bringing to surface several important biases (beyond publication) in our overall healthcare and societal culture:
    – cognitive bias: how we conceptualize medical problems and therefore appropriate interventions
    – research bias: what gets funded
    – publication bias: not just what gets published but, as in this case, how
    – reporting bias: what gets picked up in the media and how
    – distribution bias: we have in place an extremely efficient process to prescribe and get pills to people; the opposite happens with non-invasive options.

    Hopefully time and concerted efforts will help us understand how to best combine lifestyle with invasive with non-invasive options to accomplish a variety of health outcomes.

  3. Deb says:

    I am late to the story with this, but am pleased to see it highlighted here.

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