Jonathan Leo, PhD, a 1986 Macalester College graduate and professor of neuroanatomy at Lincoln Memorial University in Harrogate, Tenn., has finally reflected in print on his unhappy whistleblower role in a highly public medical ethics dust-up last spring. Leo, who also works as assistant dean of students at the small, newly established school created to place more doctors in Appalachia, became crowned with the title “Dr. Nobody” after a garden-variety letter he wrote pointing out a conflict of interest elicited a seeming authoritarian dark side at work atop the masthead at the Journal of the American Medical Association (JAMA).
As he explains this week in Society [PDF] (thank you, Furious Seasons), last spring Leo sent a letter to BMJ asking why the premier American medical journal had published a study extolling the benefits of the SSRI Lexapro for the prevention of depression in stroke patients, without notifying readers the study’s author had been paid to give speeches by the drug’s manufacturer, Forest Pharmaceuticals.
(As the New York Times recently reported, Forest has aggressively marketed Lexapro to doctors by way of speaking fees and food, an effort which put over three quarters of a million dollars in the pockets of Minnesota physicians last year. As a Pew researcher told the Star Tribune, “a lot of doctors in Minnesota have become extensions of Forest’s marketing campaign.”)
The study, which compared talk therapy and Lexapro against a placebo, found the two treatments were both effective in reducing depression after a stroke. After its publication, Leo noticed that its lead author was emphasizing only part of the study’s findings, however — the part supporting the use of antidepressants. After JAMA printed a letter by Leo asking whether it had compared the effectiveness of talk therapy to Lexapro, Leo discovered the conflict of interest and raised the issue in BMJ. (He had also written JAMA, but it had not yet published the results of its investigation.)
“Our letter was really little more than an observation based on a fifteen-second Google search plus some minor comments,” he writes in Society. “It was definitely not a groundbreaking piece of investigative journalism … anyone with access to the World Wide Web could have done the same.”
That should have been that, he thought, but Leo soon received an angry call from a top editor at JAMA demanding he retract his letter. Then — and you would have to say that this is the truly creepy part — his superiors received a similar call from JAMA editor-in-chief Catherine DeAngelis. (You would think they would have better things to do, what with health care imploding and all.) When a reporter from the Wall Street Journal got wind of the exchange, he called DeAngelis, whereupon she told him Leo was “a nobody and a nothing.”
That’s gonna look bad in print. DeAngelis published an online editorial denying she called Leo “a nobody,” but nonetheless admonishing him [PDF] for his supposed lack of discretion, and acknowledging he was told he would not be able to write for JAMA. The editorial also announced a patently unenforceable policy forbidding those who spot conflicts of interest in the journal from writing about them until the journal has completed its investigation.
Following an AMA investigation, the Journal recently replaced that editorial with one in its printed edition that neither impugns Leo nor orders all observers of medical conflicts to bow to its demands. It does, however, still request silence regarding conflict-of-interest material gleaned from Google searches. DeAngelis remains as editor.
Having survived his detour into re-education at the hands of the most powerful medical journal in the country, Leo finally tries this week to get back to the subject of what was so troubling about the original Lexapro study in the first place: It advocated treating a potential disease — the 37 percent risk of depression following stroke — in advance of its diagnosis.
“While it would certainly increase the market share for Lexapro,” he writes, “the idea of prophylactically medicating a large group of people with no psychiatric diagnosis so that a minority of them will not develop depression later on is an initiative worthy of vigorous debate.
“Where do we stop? Should we medicate all the returning veterans (a 20 percent rate of depression), every pregnant woman (10 percent to 20 percent rate), the entire population of foster children (80 percent rate of psychopathology), and all the medical students in the country (20 percent rate)?”
Leo was an economics major at Macalester (and, full disclosure, a college acquaintance of this writer, and a source whom I have quoted for stories on medications in the past). He took “a lot of biology classes,” both at Macalester and the University of Minnesota, before writing his PhD on the effects of drugs on developing brains at the University of Iowa. He credits his alma mater with the open mind that has lately given him so much trouble.
“There’s nothing like a good liberal arts education to teach someone how to think critically,” he says. “Given all that we have learned about conflicts of interest in medicine in the last few years, we could have used some more critical thinking.”
Freelancer Paul Scott, of Rochester, writes frequently about health and fitness for various media. Susan Perry is on vacation.