Study protocol violations, outcomes switching, adverse events misreporting: A peek under the hood

An extraordinary, must-read article is now available open access:

Jureidini, JN, Amsterdam, JD, McHenry, LB. The citalopram CIT-MD-18 pediatric depression trial: Deconstruction of medical ghostwriting, data mischaracterisation and academic malfeasance. International Journal of Risk & Safety in Medicine, vol. 28, no. 1, pp. 33-43, 2016

The authors had access to internal documents written with the belief that they would be left buried in corporate files. However, these documents became publicly available in a class-action product liability suit concerning the marketing of the antidepressant citalopram for treating children and adolescents.

Detailed evidence of ghost writing by industry sponsors has considerable shock value. But there is a broader usefulness to this article allowing us to peek in on the usually hidden processes by which null findings and substantial adverse events are spun into a positive report of the efficacy and safety of a treatment.

another peeking under the hoodWe are able to see behind the scenes how an already underspecified protocol was violated, primary and secondary outcomes were switched or dropped, and adverse events were suppressed in order to obtain the kind of results needed for a planned promotional effort and the FDA approval for use of the drug in these populations.

We can see how subtle changes in analyses that would otherwise go unnoticed can have a profound impact on clinical and public policy.

In so many other situations, we are left only with our skepticism about results being too good to be true. We are usually unable to evaluate independently investigators’ claims because protocols are unavailable, deviations are not noted, analyses are conducted and reported without transparency. Importantly, there usually is no access to data that would be necessary for reanalysis.

ghostwriter_badThe authors whose work is being criticized are among the most prestigious child psychiatrists in the world. The first author is currently President-elect of the American Academy of Child and Adolescent Psychiatry. The journal is among the top psychiatry journals in the world. A subscription is provided as part of membership in the American Psychiatric Association. Appearing in this journal is thus strategic because its readership includes many practitioners and clinicians who will simply defer to academics publishing in a journal they respect, without inclination to look carefully.

Indeed, I encourage readers to go to the original article and read it before proceeding further in the blog. Witness the unmasking of how null findings were turned positive. Unless you had been alerted, would you have detected that something was amiss?

Some readers have participated in multisite trials other than as a lead investigator.  I ask them to imagine that they had had received the manuscript for review and approval and assumed it was vetted by the senior investigators – and only the senior investigators.  Would they have subjected it to the scrutiny needed to detect data manipulation?

I similarly ask reviewers for scientific journals if they would have detected something amiss. Would they have compared the manuscript to the study protocol? Note that when this article was published, they probably would’ve had to contact the authors or the pharmaceutical company.

Welcome to a rich treasure trove

Separate from the civil action that led to these documents and data being released, the federal government later filed criminal charges and false claims act allegations against Forest Laboratories. The pharmaceutical company pleaded guilty and accepted a $313 million fine.

Links to the filing and the announcement from the federal government of a settlement is available in a supplementary blog at Quick Thoughts. That blog post also has rich links to the actual emails accessed by the authors, as well as blog posts by John M Nardo, M.D. that detail the difficulties these authors had publishing the paper we are discussing.

Aside from his popular blog, Dr. Nardo is one of the authors of a reanalysis that was published in The BMJ of a related trial:

Le Noury J, Nardo JM, Healy D, Jureidini J, Raven M, Tufanaru C, Abi-Jaoude E. Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ 2015; 351: h4320

My supplementary blog post contains links to discussions of that reanalysis obtained from GlaxoSmithKline, the original publication based on these data, 30 Rapid Responses to the reanalysis The BMJ, as well as federal criminal complaints and the guilty pleading of GlaxoSmithKline.

With Dr. Nardo’s assistance, I’ve assembled a full set of materials that should be valuable in stimulating discussion among senior and junior investigators, as well in student seminars. I agree with Dr. Nardo’s assessment:

I think it’s now our job to insure that all this dedicated work is rewarded with a wide readership, one that helps us move closer to putting this tawdry era behind us…John Mickey Nardo

The citalopram CIT-MD-18 pediatric depression trial

The original article that we will be discussing is:

Wagner KD, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE. A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents. American Journal of Psychiatry. 2004 Jun 1;161(6):1079-83.

It reports:

An 8-week, randomized, double-blind, placebo-controlled study compared the safety and efficacy of citalopram with placebo in the treatment of children (ages 7–11) and adolescents (ages 12–17) with major depressive disorder.

The results and conclusion:

Results: The overall mean citalopram dose was approximately 24 mg/day. Mean Children’s Depression Rating Scale—Revised scores decreased significantly more from baseline in the citalopram treatment group than in the placebo treatment group, beginning at week 1 and continuing at every observation point to the end of the study (effect size=2.9). The difference in response rate at week 8 between placebo (24%) and citalopram (36%) also was statistically significant. Citalopram treatment was well tolerated. Rates of discontinuation due to adverse events were comparable in the placebo and citalopram groups (5.9% versus 5.6%, respectively). Rhinitis, nausea, and abdominal pain were the only adverse events to occur with a frequency exceeding 10% in either treatment group.

Conclusions: In this population of children and adolescents, treatment with citalopram reduced depressive symptoms to a significantly greater extent than placebo treatment and was well tolerated.

The article ends with an elaboration of what is said in the abstract:

In conclusion, citalopram treatment significantly improved depressive symptoms compared with placebo within 1 week in this population of children and adolescents. No serious adverse events were reported, and the rate of discontinuation due to adverse events among the citalopram-treated patients was comparable to that of placebo. These findings further support the use of citalopram in children and adolescents suffering from major depression.

The study protocol

The protocol for CIT-MD-I8, IND Number 22,368 was obtained from Forest Laboratories. It was dated September 1, 1999 and amended April 8, 2002.

The primary outcome measure was the change from baseline to week 8 on the Children’s Depression Rating Scale-Revised (CDRS-R) total score.

Comparison between citalopram and placebo will be performed using three-way analysis of covariance (ANCOVA) with age group, treatment group and center as the three factors, and the baseline CDRS-R score as covariate.

The secondary outcome measures were the Clinical Global Impression severity and improvement subscales, Kiddie Schedule for Affective Disorders and Schizophrenia – depression module, and Children’s Global Assessment Scale.

Comparison between citalopram and placebo will be performed using the same approach as for the primary efficacy parameter. Two-way ANOVA will be used for CGI-I, since improvement relative to Baseline is inherent in the score.

 There was no formal power analysis but:

The primary efficacy variable is the change from baseline in CDRS-R score at Week 8.

Assuming an effect size (treatment group difference relative to pooled standard deviation) of 0.5, a sample size of 80 patients in each treatment group will provide at least 85% power at an alpha level of 0.05 (two-sided).

The deconstruction

 Selective reporting of subtle departures from the protocol could easily have been missed or simply excused as accidental and inconsequential, except that there was unrestricted access to communication within Forest Laboratories and to the data for reanalysis.

3.2 Data

The fact that Forest controlled the CIT-MD-18 manuscript production allowed for selection of efficacy results to create a favourable impression. The published Wagner et al. article concluded that citalopram produced a significantly greater reduction in depressive symptoms than placebo in this population of children and adolescents [10]. This conclusion was supported by claims that citalopram reduced the mean CDRS-R scores significantly more than placebo beginning at week 1 and at every week thereafter (effect size = 2.9); and that response rates at week 8 were significantly greater for citalopram (36% ) versus placebo (24% ). It was also claimed that there were comparable rates of tolerability and treatment discontinuation for adverse events (citalopram = 5.6% ; placebo = 5.9% ). Our analysis of these data and documents has led us to conclude that these claims were based on a combination of: misleading analysis of the primary outcome and implausible calculation of effect size; introduction of post hoc measures and failure to report negative secondary outcomes; and misleading analysis and reporting of adverse events.

3.2.1 Mischaracterisation of primary outcome

Contrary to the protocol, Forest’s final study report synopsis increased the study sample size by adding eight of nine subjects who, per protocol, should have been excluded because they were inadvertently dispensed unblinded study drug due to a packaging error [23]. The protocol stipulated: “Any patient for whom the blind has been broken will immediately be discontinued from the study and no further efficacy evaluations will be performed” [10]. Appendix Table 6 of the CIT-MD-18 Study Report [24] showed that Forest had performed a primary outcome calculation excluding these subjects (see our Fig. 2). This per protocol exclusion resulted in a ‘negative’ primary efficacy outcome.

Ultimately however, eight of the excluded subjects were added back into the analysis, turning the (albeit marginally) statistically insignificant outcome (p <  0.052) into a statistically significant outcome (p  <  0.038). Despite this change, there was still no clinically meaningful difference in symptom reduction between citalopram and placebo on the mean CDRS-R scores (Fig. 3).

The unblinding error was not reported in the published article.

Forest also failed to follow their protocol stipulated plan for analysis of age-by-treatment interaction. The primary outcome variable was the change in total CDRS-R score at week 8 for the entire citalopram versus placebo group, using a 3-way ANCOVA test of efficacy [24]. Although a significant efficacy value favouring citalopram was produced after including the unblinded subjects in the ANCOVA, this analysis resulted in an age-by-treatment interaction with no significant efficacy demonstrated in children. This important efficacy information was withheld from public scrutiny and was not presented in the published article. Nor did the published article report the power analysis used to determine the sample size, and no adequate description of this analysis was available in either the study protocol or the study report. Moreover, no indication was made in these study documents as to whether Forest originally intended to examine citalopram efficacy in children and adolescent subgroups separately or whether the study was powered to show citalopram efficacy in these subgroups. If so, then it would appear that Forest could not make a claim for efficacy in children (and possibly not even in adolescents). However, if Forest powered the study to make a claim for efficacy in the combined child plus adolescent group, this may have been invalidated as a result of the ANCOVA age-by-treatment interaction and would have shown that citalopram was not effective in children.

A further exaggeration of the effect of citalopram was to report “effect size on the primary outcome measure” of 2.9, which was extraordinary and not consistent with the primary data. This claim was questioned by Martin et al. who criticized the article for miscalculating effect size or using an unconventional calculation, which clouded “communication among investigators and across measures” [25]. The origin of the effect size calculation remained unclear even after Wagner et al. publicly acknowledged an error and stated that “With Cohens method, the effect size was 0.32,” [20] which is more typical of antidepressant trials. Moreover, we note that there was no reference to the calculation of effect size in the study protocol.

3.2.2 Failure to publish negative secondary outcomes, and undeclared inclusion of Post Hoc Outcomes

Wagner et al. failed to publish two of the protocol-specified secondary outcomes, both of which were unfavourable to citalopram. While CGI-S and CGI-I were correctly reported in the published article as negative [10], (see p1081), the Kiddie Schedule for Affective Disorders and Schizophrenia-Present (depression module) and the Children’s Global Assessment Scale (CGAS) were not reported in either the methods or results sections of the published article.

In our view, the omission of secondary outcomes was no accident. On October 15, 2001, Ms. Prescott wrote: “Ive heard through the grapevine that not all the data look as great as the primary outcome data. For these reasons (speed and greater control) I think it makes sense to prepare a draft in-house that can then be provided to Karen Wagner (or whomever) for review and comments” (see Fig. 1). Subsequently, Forest’s Dr. Heydorn wrote on April 17, 2002: “The publications committee discussed target journals, and recommended that the paper be submitted to the American Journal of Psychiatry as a Brief Report. The rationale for this was the following: … As a Brief Report, we feel we can avoid mentioning the lack of statistically significant positive effects at week 8 or study termination for secondary endpoints” [13].

Instead the writers presented post hoc statistically positive results that were not part of the original study protocol or its amendment (visit-by-visit comparison of CDRS-R scores, and ‘Response’, defined as a score of ≤28 on the CDRS-R) as though they were protocol-specified outcomes. For example, ‘Response’ was reported in the results section of the Wagner et al. article between the primary and secondary outcomes, likely predisposing a reader to regard it as more important than the selected secondary measures reported, or even to mistake it for a primary measure.

It is difficult to reconcile what the authors of the original article reported in terms of adverse events and what our “deconstructionists “ found in the unpublished final study report. The deconstruction article also notes that a letter to the editor appearing at the time of publication of the original paper called attention to another citalopram study that remain unpublished, but that was known to be a null study with substantial adverse events.

3.2.3 Mischaracterisation of adverse events

Although Wagner et al. correctly reported that “the rate of discontinuation due to adverse events among citalopram-treated patients was comparable to that of placebo”, the authors failed to mention that the five citalopram-treated subjects discontinuing treatment did so due to one case of hypomania, two of agitation, and one of akathisia. None of these potentially dangerous states of over-arousal occurred with placebo [23]. Furthermore, anxiety occurred in one citalopram patient (and none on placebo) of sufficient severity to temporarily stop the drug and irritability occurred in three citalopram (compared to one placebo). Taken together, these adverse events raise concerns about dangers from the activating effects of citalopram that should have been reported and discussed. Instead Wagner et al. reported “adverse events associated with behavioral activation (such as insomnia or agitation) were not prevalent in this trial” [10] and claimed thatthere were no reports of mania”, without acknowledging the case of hypomania [10].

Furthermore, examination of the final study report revealed that there were many more gastrointestinal adverse events for citalopram than placebo patients. However, Wagner et al. grouped the adverse event data in a way that in effect masked this possibly clinically significantly gastrointestinal intolerance. Finally, the published article also failed to report that one patient on citalopram developed abnormal liver function tests [24].

In a letter to the editor of the American Journal of Psychiatry, Mathews et al. also criticized the manner in which Wagner et al. dealt with adverse outcomes in the CIT-MD-18 data, stating that: “given the recent concerns about the risk of suicidal thoughts and behaviors in children treated with SSRIs, this study could have attempted to shed additional light on the subject” [26] Wagner et al. responded: “At the time the [CIT-MD-18] manuscript was developed, reviewed, and revised, it was not considered necessary to comment further on this topic” [20]. However, concerns about suicidal risk were prevalent before the Wagner et al. article was written and published [27]. In fact, undisclosed in both the published article and Wagner’s letter-to-the-editor, the 2001 negative Lundbeck study had raised concern over heightened suicide risk [10, 20, 21].

A later blog post will discuss the letters to the editor that appeared shortly after the original study in American Journal of Psychiatry. But for now, it would be useful to clarify the status of the negative Lundbeck study at that time.

The letter by Barbe published in AJP  remarked:

It is somewhat surprising that the authors do not compare their results with those of another trial, involving 244 adolescents (13–18-year-olds), that showed no evidence of efficacy of citalopram compared to placebo and a higher level of self-harm (16 [12.9%] of 124 versus nine [7.5%] of 120) in the citalopram group compared to the placebo group (5). Although these data were not available to the public until December 2003, one would expect that the authors, some of whom are employed by the company that produces citalopram in the United States and financed the study, had access to this information. It may be considered premature to compare the results of this trial with unpublished data from the results of a study that has not undergone the peer-review process. Once the investigators involved in the European citalopram adolescent depression study publish the results in a peer-reviewed journal, it will be possible to compare their study population, methods, and results with our study with appropriate scientific rigor.

The study authors replied:

It may be considered premature to compare the results of this trial with unpublished data from the results of a study that has not undergone the peer-review process. Once the investigators involved in the European citalopram adolescent depression study publish the results in a peer-reviewed journal, it will be possible to compare their study population, methods, and results with our study with appropriate scientific rigor.

Conflict of interest

The authors of the deconstruction study indicate they do not have any conventional industry or speaker’s bureau support to declare, but they have had relevant involvement in litigation. Their disclosure includes:

The authors are not members of any industry-sponsored advisory board or speaker’s bureau, and have no financial interest in any pharmaceutical or medical device company.

Drs. Amsterdam and Jureidini were engaged by Baum, Hedlund, Aristei & Goldman as experts in the Celexa and Lexapro Marketing and Sales Practices Litigation. Dr. McHenry was also engaged as a research consultant in the case. Dr. McHenry is a research consultant for Baum, Hedlund, Aristei & Goldman.

Concluding remarks

I don’t have many illusions about the trustworthiness of the literature reporting clinical trials, whether pharmaceutical or psychotherapy. But I found this deconstruction article quite troubling. Among the authors’ closing observations are:

The research literature on the effectiveness and safety of antidepressants for children and adolescents is relatively small, and therefore vulnerable to distortion by just one or a two badly conducted and/or reported studies. Prescribing rates are high and increasing, so that prescribers who are misinformed by misleading publications risk doing real harm to many children, and wasting valuable health resources.

I recommend readers going to my supplementary blog and reviewing a very similar case of efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. I also recommend another of my blog posts  that summarizes action taken by the US government against both Forest Laboratories and GlaxoSmithKline for promotion of misleading claims about about the efficacy and safety of antidepressants for children and adolescents.

We should scrutinize studies of the efficacy and safety of antidepressants for children and adolescents, because of the weakness of data from relatively small studies with serious difficulties in their methodology and reporting. But we should certainly not stop there. We should critically examine other studies of psychotherapy and psychosocial interventions.

I previously documented [ 1,  2] interference by promoters of the lucrative Triple P Parenting in the implementation of a supposedly independent evaluation of it, including tampering with plans for data analysis. The promoters then followed it up attempting to block publication of a meta-analysis casting doubt on their claims.

But  suppose we are not dealing the threat of conflict of interest associated with high financial stakes as an pharmaceutical companies or a globally promoted psychosocial program. There are still the less clear conflicts associated with investigator egos and the pressures to produce positive results in order to get refunded.  We should require scrutiny of protocols, whether they were faithfully implemented, with the resulting data analyzed according to a priori plans. To do that, we need unrestricted access to data and the opportunity to reanalyze it from multiple perspectives.

Results of clinical trials should be examined wherever possible in replications and extensions in new settings. But this frequently requires resources that are unlikely to be available

We are unlikely ever to see anything for clinical trials resembling the replication initiatives such as the Open Science Collaboration’s (OSC) Replication Project: Psychology. The OSC depends on mass replications involving either samples of college students or recruitment from the Internet. Most of the studies involved in the OSC did not have direct clinical or public health implications. In contrast, clinical trials usually do and require different approaches to insure the trustworthiness of findings that are claimed.

Access to the internal documents of Forest Laboratories revealed a deliberate, concerted effort to produce results consistent with the agenda of vested interests, even where prespecified analyses yielded contradictory findings. There was clear intent. But we don’t need to assume an attempt to deceive and defraud in order to insist on the opportunity to re-examine findings that affect patients and public health. As US Vice President Joseph Biden recently declared, securing advances in biomedicine and public health depends on broad and routine sharing and re-analysis of data.

My usual disclaimer: All views that I express are my own and do not necessarily reflect those of PLOS or other institutional affiliations.

6 thoughts on “Study protocol violations, outcomes switching, adverse events misreporting: A peek under the hood”

  1. It might be pointed out that citalopram was never FDA-approved for pediatric depression. When the FDA has not approved a drug for an indication, one should wonder why…It may be for a good reason, e.g. drug has been off patent for a long time, so there is no financial interest in doing more clinical trials to obtain FDA approval. On the other hand, if the drug still has plenty of patent life remaining, as was the case when this study was conducted (1999-2002), you can bet that the data supporting its efficacy and/or safety is lousy, despite what journal publications might suggest. With weak data, the sponsor will either (a) not bother submitting a new drug application (NDA) to the FDA, knowing it will be rejected, or (b) submit with high hopes, but still have the application rejected. Unfortunately, the FDA does not disclose to the world when it rejects applications — they only tell you when they approve something. So, again, when there is no approval, be wary.


  2. Citalopram (Celexa) in Kids: Why was it Ever Prescribed for Depression?
    May 13, 2016/0 Comments/by Larry Sasich

    Jureidini and colleagues’ 2016 article appearing in the International Journal of Risk & Safety in Medicine, based on unsealed court documents, concluded that the citalopram (Celexa) pediatric depression trial CIT-MD-18 showed no statistically significant difference between citalopram and placebo.[1] This is in contrast to the published report of CIT-MD-18 in 2004 that found citalopram was safe and significantly more efficacious than placebo for children and adolescents with depression.[2] Jureidini and colleagues point out the possibility of potential harm from citalopram to children and adolescents with effects on developing brains and an increase in the risk of suicidal thinking and behavior.[1]

    A nagging, unaddressed question is why in light of the fact that citalopram was never approved by the Food and Drug Administration (FDA) for depression in younger populations was it prescribed without convincing evidence of a benefit that only leaves patients with the risks from the drug?

    Information has been publically available free of charge from the FDA warning about the use of citalopram in children and adolescents for the past 18 years.

    Citalopram (Celexa) was approved for sale in the US in July 1998. The Pediatric Use section of the drug’s FDA approved professional product label stated at the time: “Safety and effectiveness in pediatric patients have not been established.”[3]

    Other information accessible on the FDA’s Web site reveals the manufacturer’s request for use of citalopram in pediatric patients, referred to as a Pediatric Supplement, was rejected in September 2002.[4,5] The studies submitted to the FDA in support of the Pediatric Supplement included study CIT-MD-18. The FDA review of these studies concluded that efficacy in this population [pediatric] with citalopram had not been established.[6]

    In February 2005, the FDA required a Boxed Warning in the professional product labels all antidepressants including citalopram. This is the strongest type of warning information that the agency can require for a drug.[4]

    The Boxed Warning clearly states that citalopram is not approved for use in pediatric patients. A pooled analyses of short-term 4 to 16 week placebo-controlled trials of 9 antidepressant drugs including selective serotonin re-uptake inhibitors (SSRIs) and others in children and adolescents with major depressive disorder (MDD), obsessive compulsive disorder (OCD), or other psychiatric disorders revealed a greater risk of adverse events representing suicidal thinking or behavior during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients receiving antidepressants was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. Two placebo-controlled trials in 407 pediatric patients with MDD have been conducted with citalopram, and the data were not sufficient to support a claim for use in pediatric patients.[4]

    Jureidini and colleagues note sticking similarities between the citalopram CIT-MD-18 trial and Study 329, a trial comparing paroxetine (Paxil) to imipramine in adolescents with depression.[1] A re-analysis of Study 329 [7] concluded, contrary to the original Study 329 publication [8], that neither paroxetine nor imipramine was statistically or clinically more effective than placebo, while both increased harms.

    The fact that paroxetine had not been shown to be safe and effective in pediatric patients was made publicly available on the FDA website in 1998, three years before the publication of the original Study 329. The professional product label for paroxetine since the mid-2000s contains a Boxed Warning stating that the drug is not approved for use in pediatric patients and that antidepressants increase the risk of suicidality in this patient population.[9]

    The most sticking similarity, from a safety perspective, between the citalopram CIT-MD-18 trial and the re-analysis of the paroxetine Study 329 is that in both cases information was available on the FDA Web site and professional product labels that these drugs were not approved for use in younger populations. This was 18 years for citalopram and 14 years for paroxetine.

    Jureidini and colleagues [1] note that pediatric antidepressant consumption is high and increasing, led by prescribing trends in the US.[10] The reason for this is unclear given the publically available information that was, and is, available warning against use of these drugs from the FDA from the time these drugs were first approved. Several possibilities exist that may explain, in part, the inappropriate prescribing of these drugs in children and adolescents.

    Commercial information (advertising) may have a greater influence on physicians’ prescribing behavior than scientific information.[11] A correlation has been found between payments to physicians and the prescribing of brand name cholesterol lowering statin drugs.[12] Similar results are possible with brand name antidepressants. A national survey of board certified internists and specialist’s exposed substantial shortfalls in knowledge of the meaning of FDA approval that may lead physicians to overprescribe newly approved drugs. Seventy-three percent of respondents believed that FDA approval typically means that a drug is as effective as other drugs approved to treat the same condition.[13]

    Regardless of the reasons that citalopram and paroxetine are prescribed for an unapproved use, in fact, a disapproved unapproved use, patients and the parents of patients should have this information in their hands. Patient safety advocates should strongly encourage the public to access the professional product labels and other drug safety information available from the FDA or from information consistent with FDA recommendations.

    1. Jureidini JN, Amsterdam JD, McHenry LB. The citalopram CIT-MD-18 pediatric depression trial: Deconstruction of medical ghostwriting, data mischaracterization and academic malfeasance. Int J Risk Saf Med. 2016; 28 (1):33-43.
    2. Wagner KD, Robb AS, Findling RL, Jin J, Gutierrez MM, Heydorn WE. A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents. Am J Psych. 2004;161(6):1079-83.
    3. Forest Pharmaceuticals, Inc. Celexa (citalopram) Final Printed Labeling, 1998. At Accessed May 10, 2016.
    4. United States Food and Drug Administration. New Pediatric Labeling Information Database, March 5, 2016. At Accessed May 10, 2016.
    5. United States Food and Drug Administration. Medical, Statistical, and Clinical Pharmacology Reviews of Pediatric Studies Conducted under Section 505A of the Federal Food, Drug, and Cosmetic Act, as amended by the FDA Safety and Innovation Act of 2012 (FDASIA). At Accessed May 10, 2016.
    6. Hearst ED, United States Food and Drug Administration. Pediatric Supplement Review and Evaluation of Clinical Data, Celexa (citalopram), September 12, 2002. At Accessed May 10, 2016.
    7. Le Noury J, Nardo JM, Healy D, Jureidini J, Raven M, Tufanaru C, Abi-Jaoude E. Restoring Study 329: Efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ. 2015;351:h4320.
    8. Keller MB, Ryan ND, Strober M, et al. Efficacy of paroxetine in the treatment of adolescentcmajor depression: a randomized, controlled trial. J Am Acad Childc Adolesc Psychiatry 2001;40:762-72.
    9. Sasich LD. Paroxetine and Study 329: what we already knew andwhen. BMJ 2015; 351: h5411.
    10. Wijlaars LP, Nazareth I, Petersen I. Trends in depression and antidepressant prescribing in children and adolescents: A cohort study in The Health Improvement Network (THIN). PLoS One. 2012;7(3):e33181.
    11. Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med. Jul 1982;73(1):4-8.
    12. Yeh JS, Franklin JM, Avorn J, Landon J, Kesselheim AS. Association of Industry Payments to Physicians With the Prescribing of Brand-name Statins in Massachusetts. JAMA Intern Med. May 9 2016.
    13. Kesselheim AS, Woloshin S, Eddings W, Franklin JM, Ross KM, Schwartz LM. Physicians’ Knowledge About FDA Approval Standards and Perceptions of the “Breakthrough Therapy” Designation. JAMA.2016; 315(14):1516-1518.


  3. As someone who’s life depends on medicine I’d would make it mandatory to release all internal documents, including emails, meeting memos, etc. in every FDA application of drug. I think public interest trumps private one in drug safety as applicant has huge economical interest.


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