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Elvira Craig de Silva, DSW, ACSW
President, National Association of Social Workers (NASW)

Elizabeth Clark, PhD, ACSW
Executive Director, NASW, and President, NASW Foundation

Letter History
View Original E-mail from NASW: October 6, 2006
View Letter to NASW: December 1st, 2006
View Reply from NASW: December 7th, 2006
View Response to NASW: January 19, 2007

On October 6, 2006, the National Association of Social Workers (NASW) sent to its Specialty Practice Sections on mental health and private practice an emailed “Invitation to Join The National Adherence Initiative for Schizophrenia.” An article in the November issue of NASW News also announces and describes the initiative (1).

The brief text in the email asked social workers to consider enrolling “in a nationwide data collection effort.” It stated: “Partial adherence is a significant problem in the treatment of schizophrenia … and can affect up to 75% of patients.” It invited participants to “identify up to 10 clients with schizophrenia that you feel are at risk for partial adherence.”

The last line of the text informed that this initiative “is sponsored by Janssen, L.P. in partnership with NASW.” The pharmaceutical company Janssen, a subsidiary of Johnson & Johnson, markets Risperdal (risperidone), an antipsychotic drug that grossed $2.3 billion in US sales in 2005 (2). Social workers who enrolled received a packet from Janssen, with the “study instrument,” that spoke of nothing but the importance of drug treatment adherence for schizophrenia.

The undersigned social workers and social work educators and researchers are, for several reasons, concerned about the NASW’s active participation in this pharmaceutical company marketing initiative.

First, now is a time of unprecedented awareness of the pharmaceutical industry’s stake in framing how distress and mental disorders are seen and how they are treated (3). This industry has used every means at its disposal—including one-to-one enticement of professionals (4), sponsorship and delivery of continuing “education” (5), sponsorship of advocacy groups, ghost-writing of “scientific” articles and dissemination of unsupported “medication algorithms” (6), direct-to-consumer advertising, intense legislative lobbying (7), as well as suppression of research findings, illegal marketing of psychotropic drugs for off-label purposes (8), and cash payments to state officials to include atypical antipsychotics on Medicaid formularies (9)—to remain the dominant player in health and mental health. Regardless of evidence of drugs’ efficacy or safety, the industry’s unrivaled ability to spread money to influence thinking, practice, and policymaking means that the mental health system serves the industry, rather than the opposite.

Second, as non-industry funded studies increasingly identify the limitations of its products and exaggerated claims made about them, the industry greatly diversifies marketing efforts to dilute any impact of bad news on drug sales. Countless seemingly “independent” professional and advocacy activities are today carefully orchestrated and funded by marketing firms to reach specific prescription goals (8). The stark truth is that no mental health profession and no professional activity is safe from drug industry influence. Moreover, mere awareness of the issue cannot guard against being used as part of the industry’s marketing efforts. As authors from psychology have recently recommended, mental health professions need to build a “firewall” between marketing and science. (10) Authors from medicine similarly call for “a strict sequestration of commercial and scientific activities, and a fundamental internal reevaluation of the interactions between individual physicians, professional organizations, and the industry” (8). Did the NASW consider such warnings, now so numerous in the literature as to defy counting?

Third, it seems to us that the NASW did not sufficiently scrutinize an “adherence initiative” in 2006. Treatment compliance is an old issue in schizophrenia care. Everyone in this field knows that antipsychotic drugs’ unpleasant effects make them extremely undesirable to patients. The Janssen initiative closely follows the government-sponsored CATIE studies’ findings that three quarters of patients on atypical antipsychotics such as Janssen’s Risperdal—falsely touted for a decade as vast improvements over older drugs—stop taking their prescribed medication because of “inefficacy, intolerable adverse effects, or other reasons” (11).

The study instrument mailed to social workers consists of eight “yes/no” questions, each describing a “deficit” in patients that would put them “at risk” of “partial adherence.” In our view, no information not already well known from dozens of previous studies on adherence to neuroleptic treatment, including the $45 million CATIE studies on nearly 1,500 patients, is likely to come from this Janssen-NASW study. The adherence initiative repeats that “partial adherence” is a significant problem in the treatment of schizophrenia—but the more significant problem lies rather with the drugs’ now well established ineffectiveness and adverse effects.

Fourth, and more to the point, Janssen’s exclusive patent to market oral risperidone will expire in 2007, and the company stands to lose significant revenue as cheaper generic versions come to market. Janssen is therefore now emphasizing the long-acting injectable version of risperidone, which it markets as Risperdal Consta—on which it still holds patent for several more years (and which sells for more than the oral version). The history of antipsychotic drug use shows that one notion, and one notion only, has ever justified using long acting injectable antipsychotics: adherence (compliance). In this light must Janssen’s “adherence initiative” be more fully appreciated.

Finally, even as social work researchers lead the questioning of a failed paradigm constraining explanation and intervention in the lives of persons who experience psychosis (12), we are mystified that the NASW allies itself with Big Pharma, rather than lead the unbiased search for veritable innovations in care. Improvement rates in schizophrenia, after more than 50 years of drug treatment, are worse now than they were 80 years ago (13). Given that mental disorders and psychosis are strongly correlated with environmental factors such as low socioeconomic status (14) and childhood trauma (15), the NASW should formally endorse the preventive research of social workers that attempts to protect youth from harmful experiences or to foster healthy lifestyles and psychological resilience. Rather than lend even more credence to pharmaceuticals, the NASW should spearhead an initiative to publicize available psychosocial treatments that teach coping skills, interpersonal skills, and independent living skills that allow clients to function with minimal reliance on costly and potentially harmful drugs.

The undersigned consider this “adherence initiative” a campaign directly promoting the drug treatment of schizophrenia and indirectly promoting Janssen’s image and products. The “adherence” sought is that of social workers and other professionals to a treatment model guided by drugs—Janssen’s drugs. That this initiative seeks to enroll social workers in a seeming research effort for the benefit of patient care simply cannot be taken as its primary purpose. More than anything, the initiative expresses to outside observers that yet another professional organization could not remain independent of the pharmaceutical industry’s influence.

It is our understanding that Janssen initiated the contact with the NASW, remunerated the consultant from the NASW, and made a donation to the NASW Foundation in return for this collaboration. (No mention of this donation appears in the NASW News article.) The other organizations partnering with Janssen in this initiative include the National Alliance on Mental Illness, the (American) Psychiatric Nurses Association, and Schizophrenics Anonymous, all of which benefit from drug company largesse.

We request, first, that the NASW publicly backtrack on this initiative; second, that for the sake of transparency the NASW discloses the amount that Janssen donated to the NASW Foundation; and third, that the NASW inform its membership and the broader constituencies it aims to serve precisely how it intends to protect itself from other pharmaceutical industry initiatives certain to follow this most unfortunate precedent.

 

Signed:

David Cohen, PhD
Professor, Florida International University

Stephen E. Wong, Ph.D.
Associate Professor, Florida International University

Tomi Gomory, PhD
Associate Professor, Florida State University

Jeffrey Lacasse, PhD Candidate
Visiting Lecturer, Florida State University

Dennis Saleeby, PhD
Professor Emeritus, University of Kansas

Stuart A. Kirk, DSW
Professor, University of California, Los Angeles

John Bola, PhD
Assistant Professor, University of Southern California

Eileen Gambrill, PhD
Professor, University of California, Berkeley

Linda Vinton, PhD
Professor, Florida State University

Scott Ryan, PhD
Associate Professor, Florida State University

Kia J. Bentley, PhD
Professor, Virginia Commonwealth University

C. Aaron McNeece, PhD
Dean & Professor, Florida State University

Wendy Crook, PhD
Associate Professor, Florida State University

Mark A. Mattaini, DSW
Associate Professor, University of Illinois at Chicago

Nicholas Mazza, PhD
Professor, Florida State University

Blace Nalavany, Ph.D.
Assistant Professor, East Carolina University

Devon Brooks, Ph.D.
Associate Dean for Faculty Affairs and Associate Professor, University of Southern California

D. Lynn Jackson, Ph.D.
Director of Field Instruction, University of North Texas

Donni P. Whitsett, Ph.D., University of Southern California

REFERENCES

1. Pace, P. R. (2006, November). NASW joins adherence initiative. NASW News, p. 10.

2. IMS Health. (2006). Commonly requested therapeutic class and product update (February 2006). Retrieved November 21, 2006 from: http://www.imshealth.com/ims/portal/front/articleC/0,2777,6599_18731_77056778,00.html

3. Moynihan, R., & Cassels, A. (2005). Selling sickness: how the world’s biggest pharmaceutical companies are turning us all into patients. New York: Nation Books.

4. Elliott, C. (2006, April). The drug pushers. The Atlantic Monthly, pp. 82-93.

5. Elliott, C. (2004, Sept-Oct.). Pharma goes to the laundry: Public relations and the business of medical education. Hastings Center Report, pp. 18-23.

6. Healy, D. (2006). Manufacturing consensus. Culture, Medicine & Psychiatry, 30, 135-156.

7. Angell, M. B. (2004). The truth about drug companies: How they deceive us and what to do about it. New York: Random House.

8. Steinman, M. A., Bero, L. A., Chren, M.-M., & Landefeld, S. C. (2006). The promotion of gabapentin: An analysis of internal industry documents. Annals of Internal Medicine, 145, 284-293.
9. Moynihan, R. (2004). Drug company targets US state health officials. British Medical Journal, 328, 306.

10. Antonuccio, D. O., & Danton, W. G. (2003). Psychology in the prescription era: Building a firewall between marketing and science. American Psychologist, 58, 1028-1033.

11. Lieberman, J. A., et al. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. The New England Journal of Medicine, 335, 1209-1223.

12. Bola, J. R., et al. (2006). Predicting medication-free treatment response in acute psychosis: cross-validation from the Finnish Need-Adapted Project. Journal of Nervous & Mental Diseases, 194, 732-739.

13. Hegarty, J., Baldessarini, R.J., Tohen, M., Waternaux, C., & Oepen, G. (1994). One hundred years of schizophrenia: A meta-analysis of the outcome literature. American Journal of Psychiatry, 151(11), 1409-1416.

14. Hudson, C. G. (2005). Socioeconomic status and mental illness: Tests of the social causation and selection hypothesis. American Journal of Orthopsychiatry, 75, 3-18.

15. Read, J., van Os, J., Morrison, A. P., Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112, 330-350.


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