JAMA , Free Speech, and Conflicts of Interest

I recently co-authored a letter to the BMJ, pointing out anauthor’s undisclosed conflict of interest related to a study(http://jama.ama-assn.org/cgi/content/full/299/20/2391)pub-lishedintheJournal of the American Medical Association(JAMA). Our letter (http://www.bmj.com/cgi/eletters/338/feb05_1/b463) was really little more than an observationbased on a fifteen-second Google search plus some minorcomments. It was definitely not a groundbreaking piece ofinvestigative journalism based on top-secret files, and anyonewith access to the World Wide Web could have done thesame. The study we wrote about examined the use ofLexapro, an SSRI, in stroke patients. The author of the study,a psychiatry professor, had not disclosed that he had servedon the speaker’s bureau of Forest Pharmaceuticals, themanufacturer of Lexapro. Compared to the recent revelationsabout academic psychiatrists and their unreported side dealsworth hundreds of thousands, in some cases millions, ofdollars with pharmaceutical companies, what we wrote aboutwas minor. Although our letter said nothing negative aboutJAMA, and under normal circumstances would likely havebeen read by only a handful of people, the editors wereextremely upset and their subsequent comments ( http://blogs.wsj.com/health/2009/03/13/jama-editor-calls-critic-a-nobody-and-a-nothing/ )toaWall Street Journal reporter that I was a“nobody” and “nothing” thrust the issue into the headlines.The ultimate goal of the research group who authored thestudy is to prevent depression from developing in strokepatients not treatment of depression but the prevention ofdepression, an important distinction. While it would certainlyincrease the market share for Lexapro, the idea of prophy-lactically medicating a large group of people with nopsychiatric diagnosis so that a minority of them will notdevelop depression later on is an initiative worthy ofvigorous debate. In this trial they looked at three groups:Lexapro, problem solving therapy, and placebo. BothLexapro and therapy beat placebo. Considering that thereare about 6 million stroke patients in the United States, andthat, according to several data sets, about 37%, or 2.2 millionpeople, will develop depression, this represents a largemarket for the pharmaceutical companies, especially whenyou consider it involves prescribing a medication for peoplewho do not have a diagnosis of depression. Following itspublication, the authors were quoted (http://www.usatoday.com/news/health/2008-05-27-stroke-depression_N.htm)inthe media as saying that every stroke patient who couldtolerate the medicine should be started on an SSRI. At thevery least, the slippery slope comes to mind at this point. Ifwe are going to try and prevent depression in one high riskgroup by treating everybody in the group before they areclinically depressed, then what about other high risk groups?Where do we stop? Should we medicate all the returningveterans (a 20% rate of depression), every pregnant woman(10% to 20%), the entire population of foster children (80%rate of psychopathology), and all the medical students in thecountry (20% rate)?A week after their “Dr. Nobody” comment, the editorspublished an editorial, in which they spilt a considerableamount of ink cataloguing my sins, and they used my caseas the impetus for a new policy that puts restraints on whatpeople can say about JAMA. Whereas their initial com-ments could have been brushed off as having been made in“the heat of the moment,” and would have been quicklyforgiven in the blogosphere and op-ed pages, this was notthe case with the editorial, which clearly required more time