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End of the line for the gravy train?

Pharma giant AstraZeneca will no longer fund doctors' travel to medical congresses, becoming the first leading drugmaker to renounce this common perk.

Announcing the step at an industry conference in Istanbul, that pharma "is a force for good. But if we're honest with ourselves ... we’re often seen as the bad guys."

He cited a recent in the U.S., which found that only 11% of Americans rated big pharma as trustworthy, when even banks had scored 20%. The same poll also found, though he didn't mention it, that pharma, along with oil, was the industry Americans most wanted to regulate more strictly.

His company had resolved to address the problem by "never doing anything that could be misinterpreted," said Mr Brennan. "We have decided that we will no longer pay for doctors to attend international scientific and medical congresses but will instead focus our educational efforts on local educational opportunities for healthcare professionals."

He added an interesting take on the doctor/pharm rep relationship from the other side of the fence: "I know from my own experience as a sales representative, you will encounter people who will ask for gifts, or other inducements. And they will threaten to take their business elsewhere, if you don’t acquiesce ... we have made it clear that our sales force have to say no."

It's likely that other pharma companies will follow AstraZeneca's lead. The industry acted in a fairly coordinated manner in abandoning free gits like mugs and mousepads in recent years. And the announcement carries extra significance because Brennan, the only leading pharm CEO to come from a background in sales rather than medicine or chemistry, is also president of the the International Federation of Pharmaceutical Manufacturers and Associations.

The drug industry has come under pressure recently over dealings abroad, particularly with employees of foreign public health services, including doctors. AstraZeneca and other British companies have had to contend with a new bribery act in the UK, while in the United States has been investigating big pharma under the Foreign Corrupt Practices Act (FCPA). Johnson & Johnson last month to settle British and American charges that it paid kickbacks to win business overseas. AstraZeneca itself is being investigated under FCPA for its dealings in China.

Army of psychopaths to spring up in 2013

If you thought grim things were forecast for 2012, just wait till 2013. An army of psychopaths will spring up overnight. Many of our friends and neighbours will suddenly develop alcohol problems. In fact, eminent psychiatrists fear that millions of us will slip over that ephemeral frontier that separates the normal from (to use the proper medical term) the Crazy.

That's because 2013 will see the fifth coming of the brain-doctor's bible, the Book that tells us who is normal and who has a "disorder" - the Diagnostic and Statistical Manual of Mental Disorders. Is that weird neighbour just a jerk or does he have a syndrome? DSM-5 will decide.

Maybe he's a psychopath. Because, after 33 years' absence, the honest psychopath makes his comeback in DSM-5. In DSMs III and IV, psychopaths were hidden under the euphemistic category of Antisocial Personality Disorder. But the latest draft of DSM-5 will brand these undesirables as Antisocial/Psychopathic Type, which has a fine condemnatory ring. In fact it sounds more like a judgement than a diagnosis. You can presumably cure a disorder, but can you cure a "type"?

If anyone thinks this is all just semantics, consider the impact in recent years of three disorders that were redefined by DSM-IV in 1994: attention deficit disorder, autism, and child bipolar disorder. The Chairman of the DSM-IV task force, psychiatrist Allen Frances, his panel "inadvertently contributed to three false 'epidemics'."

"I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences," wrote Dr Frances. "Clearly, our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system."

DSM-5 offers the opportunity to undo some mistakes in DSM-IV. The autistic spectrum was a bit of a dog's breakfast, and the next iteration will try to bring it some order, doing away in the process with Asperger's Syndrome and the unpopular diagnosis Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). It seems a little harsh on Dr Asperger, whose name is being de-immortalized, but fair enough.

But many more new diagnoses are trying to creep in, some pushed by eager researchers, others befriended by lawyers, all surely welcomed by big pharma. Each seeks to push the boundary between Normal and Crazy so that more people will fall into the second category. The draft includes a Hoarding Disorder. The proposed Mixed Anxiety Depression will capture millions who don't qualify for Major Depression but who constitute what we call 'the worrying type'. Irritable people who throw tantrums will have Disruptive Mood Dysregulation Disorder. There's Minor Neurocognitive Disorder for those with expected cognitive decline of ageing that's too mild to justify a diagnosis of Mild Neurocognitive Disorder .

There's also constant pressure to ease the criteria for existing conditions. A finds that the prevalence of alcohol use disorders is 62% higher under DSM-5 criteria than under DSM-IV. Adult ADD is also getting more broadly defined. It's the medicalization of normal, if bad, behaviour that scares Dr Frances and many other critics.

Book needs appendectomy
To be fair, most of the worst ideas come from outside the American Psychiatric Association committees responsible for the drafts. Some of the silliest have already been rejected. Divorce lawyers will not get their "parental alienation syndrome", which would have allowed them to counter child abuse allegations by alleging that Mommy had turned Johnny against Daddy.

Disorders that have made it this far in the process, however, are so far advanced that to ignore them would apparently be rude, so those that don't get a disease code are likely to end up in the Appendix on Axes for Further Study, which is beginning to sound like a smorgasbord of half-baked ideas, about as useful as a human appendix. One pseudo-condition that's already definitely heading there is Hypersexual Disorder, which has been derided as a philanderer's charter.

The behavioural "addictions" - shopping addiction, computer game addiction, internet addiction, will also be relegated to the appendix, except for compulsive gambling, which became officially crazy in 1994 with DSM-IV. It makes the leap from humble Impulse Disorder to become the first recognized Behavioural Addiction. Can the others be far behind?

One new condition that teeters between recognition and the obscurity of the appendix is Attenuated Psychosis Syndrome, a diagnosis intended to catch mostly young people who might be at risk of developing a real psychotic episode later in life, but who have never met any criteria for one. Those diagnosed, including the many false positives, would be treated with atypical antipsychotics, costly drugs with a heavy burden of side effects. The creators of DSM-5 declare themselves torn on this one, and welcome outside comment. In fact the whole process is in an open comment period until June 15. You can have your say .
OD