Monday, July 7, 2014

Alkermes And The Pharmaceutical Company Dynamic

I was reading this month's Journal of Clinical Psychiatry and came across a dimension of the psychiatrist - pharmaceutical company  dynamic that is rarely the object of analysis.  I can't put the ad here because it appears to be copyrighted so I will have to describe it and you can see the graphic here.  There is a picture of a man in a brown pullover sweater in the middle.  His hands are pressed together and he has a concerned look as he looks toward a younger man who is slightly unkempt to his right.  The younger man is staring away and making no eye contact.  To the far left behind a counter is a woman wearing a white coat and protective gloves as she swirls an Erlenmeyer flask containing bluish liquid.  My theory of the mind says the man in the middle is a psychiatrist, the man to his right is the patient and the woman is some kind of biomedical researcher.  The copy reads:

"Your challenges are our challenges.  At Alkermes, we're inspired by the challenges that psychiatrists face every day.  We share your dedication to patients living with schizophrenia, depression or addiction.  So when we develop new treatments, we begin with a compassionate understanding of your real world needs.  We stand ready to improve the health of your patients."

I am sure that most psychiatrists can see this for what it is - advertising and would have suggested that Alkermes take a less melodramatic approach.  Alkermes is relatively new to CNS pharmaceuticals but it has drugs in the pipeline for both schizophrenia and depression.  Many addiction psychiatrists are used to seeing their version of long acting naltrexone called Vivitrol.  I have never seen a sales representative from the company.  Pharmaceutical company reps have taken a hit with the new anti-Pharma religion and they are banned from most clinics, hospitals, and academic settings in my area.  The rap against them has been that they were essentially influencing physicians to prescribe their products by financial incentives in the form of gifts or in many cases personal relationships, or a combination of both.  A secondary issue was that some of the Pharma associated educational activities were more or less well disguised advertising in a number of forms.

This new approach by Alkermes taps into an area with psychiatrists that I have not previously seen as an area of focus.  It is basically saying to the most beleaguered physicians: "We understand what you are up against and we are on your side."  Although it seems like a clumsy first attempt, the message is powerful.  If you are a senior psychiatrist and have practiced as long as I have - you realize that apart from any good colleagues that you might have from time to time - there is nobody on your side.  Many psychiatrists are professionally isolated and may see their colleagues at an annual meeting.  Others in larger organizations are mismanaged to the point where their colleagues are seen as competition rather than resources.  There is nobody on your side professionally or in your attempts to treat your patients.  In fact as I have illustrated here, there are many people in your way when you try to provide care to patients.  They are incentivized to get you to ration care and in many cases that comes down to providing no care.

The Alkermes approach captures at least a part of the unconscious reason for affiliating oneself with a friendly entity.  My guess is whoever is behind it does have an understanding of what is going on with physicians and psychiatrists in particular.  A pharmaceutical company ad will never make it explicit,  but there is also an asymmetry in the relationship they are  discussing.  Bundling the cost into a pharmaceutical product is a much more effective way to get reimbursed than bundling cost in the form of a psychiatrist.

Even though they appear to feel our pain - they don't really have to.

George Dawson, MD, DFAPA

Supplementary 1:  Breaking news from the U.S. Patent office:

Aripiprazole lauroxil: patent app 13/607,066 covers methods of treating schizophrenia, mania, bipolar disorder, anxiety or depression by administering a broad class of compounds including aripiprazole lauroxil.

ALKS 5461: patent app 13/715,198 covers composition of matter.

ALKS 3831: patent app 13/215,718 covers the attenuation of weight gain associated with olanzapine in patients with schizophrenia by administering the combination of samidorphan (formerly ALKS 33) and olanzapine.

ALKS 7106: patent app 14/169,305 covers composition of matter.

For full details read the press release from the Alkermes web site.


  1. When they get really good at it they will be making ads like this

    Not that we don't have these types of ads from time to time, but in SE Asia they have perfected them, and their viral popularity on social media hasn't gone unnoticed by marketers.

    Alkermes appeal to clinicians may be breaking new ground but it looks like altruism might just beat out sex for selling these days. After all, you can get sex anywhere, but altruism is getting harder and harder to find.

    You know, the Unsung Hero really is a good video; too bad it is also an advertisement.

  2. "Sell the sizzle, not the steak" is hardly new in advertising. Although I can't quickly find examples online, I have no doubt that pharma ads to doctors have appealed (pandered?) to our emotions from the very beginning. Variations on the Alkermes ad appear regularly in journals: a troubled patient with a face depicted as shards of a broken mirror is literally "made whole" in the "after" picture. Storm clouds in the "before" picture become blue skies. Etc. There's nothing the least bit subtle or sneaky about this, it's how companies sell everything from cars to canned soup. Meds are no exception:

    Perhaps I misunderstand what you mean by "anti-Pharma" being a religion. I'm glad the industry exists, but I don't approve of its marketing efforts, either to doctors or the public. Pharma reps visited the older psychiatrists in my suite for years; I always found it awkward that uninvited (by me) salespeople felt entitled to sit in my waiting room and try to strike up conversations with me. I thought it would make about as much sense to invite our ubiquitous San Francisco panhandlers into our waiting room, so they could make their pitches. Now that the older docs have retired and we have new faces here, none of us will allow their promotional materials and glad-handing. If that's a religion, hallelujah.

    It's sad — and a little ominous — that some senior psychiatrists feel no one is on their side, and therefore find sentimental marketing tropes appealing. By avoiding the grindstone of CorpMed and managed care, by having colleagues nearby who practice likewise, by staying involved in resident education at a nearby medical center, and by conversing with fellow psychiatrists in the blogosphere, I don't feel isolated or unsupported professionally. I'd likely feel beleaguered and discouraged, though, if I worked in a corporate setting. As something of an outsider to that world, I watch with fascination how Pharma can supply both the meds that constitute the sole treatment modality in such settings, as well as the "sympathy" that the providers need to feel valued and understood there.

    1. I think that the "sizzle" used to be: "This is the next great drug coming down the pike and it is better than what was previously available?" Most psychiatrists have the experience of listening to patients requesting the next great drug. I think that element of pharmaceutical advertising has been one of the more compelling marketing techniques. In fact, all of the ads I have read for the past 30 years pretty much say that. Before you disagree, I was on a P & T Committee in the 1990s and had to listen to a special appeal from psychiatrists that fluoxetine was an SSRI with special properties and that we should allow it on the formulary so that only psychiatrists could prescribe it without prior authorization. The reason for that very emotional appeal – strictly advertising.

      I am certainly not suggesting that this is subtle or sneaky, in fact I think that one of the reasons that I am not obsessing about the behavior of pharmaceutical ads on blogs that purport to “Keep psychiatry honest since 2007” is that I know what advertising is and I am not threatened by it. If I can watch a Cadillac commercial or a Corvette commercial and not run out and buy a new car I doubt that a melodramatic pharmaceutical ad is going to do anything. Don’t mistake me for the people who are pouring over pharmaceutical company papers from 20 and 30 years ago.

      Not approving marketing efforts of Big Pharma seems like not understanding advertising to me. For the record, I guess you would classify me as an “older psychiatrist”. I have not seen a Pharma rep, eaten any of their free food, or accepted any of their promotional materials in about 30 years.

      I come from a place that is cold and desolate. Nobody there expects anybody to be on their side. People expect people to mind their own business and leave them alone. In terms of people being on my side, the only exceptions I have found have been a few college professors, a couple of fellow Peace Corps volunteers and of course my wife. I would certainly never expect that to come from my any of the people I do business with and definitely not a Pharmaceutical company. And you are correct, working for corporations I have been in contact with administrators who were absolutely toxic.

      I guess I should have made that more explicit in the post, but I hope this will do.

  3. Why do you stay in a place that is cold and desolate?

    Because that's where the patients are? Lighting a candle in the darkness?

  4. I like the weather and I like to speedskate. My reference to the culture was provided to suggest that may have been the origin of my blue collar skepticism of the intentions of corporations, unions, and politicians. In the 21st century I would add bloggers to that list.