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.


  1. Ginger Campbell, MD on March 24, 2009 at 11:38

    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 on March 24, 2009 at 4:36

    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 on March 26, 2009 at 12:10

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

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SHARPBRAINS es un think-tank y consultoría independiente proporcionando servicios para la neurociencia aplicada, salud, liderazgo e innovación.

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