Two essays published in separate periodicals this week raise troubling questions about the extent to which psychiatrists may be unduly influenced by the pharmaceutical industry, and how this relationship may effect public trust in psychiatry. The upshot? The concern about corruption, or at least the appearance of corruption is palpable. Sigmund Freud (see photo) would not be pleased. Interestingly, one of the authors is Tom Insel, the director of the National Institute of Mental Health (click on read more below).
For instance, Lisa Cosgrove and Harold Bursztajn write in Psychiatric Times that they looked at the two philanthropic arms of the American Psychiatric Association - the American Psychiatric Foundation and the American Psychiatric Institute for Research and Education - and found that APF’s 15-member board includes four high-level pharma execs that either make meds recommended by APA or are developing products targeted to treat mental disorders. Other board members include two more with industry ties and a senior vp at Fleishman Hillard, the public relations firm whose clients include six drugmakers.
APF’s corporate advisory council lists drugmakers, they continue, that contribute "significant funding" to APF and that make meds recommended in the APA’s clinical practice guidelines. Although it was not possible to discern the total amount of industry funding given to APF, in fiscal year 2008 APF lists 11 pharmaceutical companies and 1 medical device manufacturer that contributed monies; 6 of the companies are listed as giving $40,000 “and above” per year.
They go on to write that APIRE, like APF, doesn't require disclosure of financial conflicts of interests, and that nine of 16 APIRE board members have ties to drugmakers. They also note current disclosure policies don't require reporting of pooled industry money to academic departments, units, hospitals, and med schools. And because there is no independent monitoring of industry ties, they maintain "underreporting is very likely a problem. For example, one board member who reported 'no disclosure' in an APA publication was found to be on the speakers’ bureau of multiple pharmaceutical companies."
Then they analyzed the DSM-IV, DSM-V work group panels, and the authors of the DSM-based Practice Guidelines, and found what they call "a striking lack of balance between industry-tied and industry-independent work group members." Approximately 68 percent of the members of the DSM-V task force reported having industry ties, an increase of 2 percent over the proportion of DSM-IV task force members with such ties.
And of the 137 DSM-V panel members who posted disclosure statements, 56 percent reported industry ties, such as holding stock in drugmakers, serving as consultants, or serving on company boards, which amounts to "no improvement" over the 56 percent of DSM-IV members who had industry relationships. Also, 90 percent of the authors of three major clinical practice guidelines had financial ties to drugmakers explicitly or implicitly identified in the guidelines as recommended therapies for the respective mental illnesses.
Meanwhile, Tom Insel, the director of the National Institute of Mental Health writes in this week's Journal of the American Medical Association that "as public trust in the pharmaceutical industry has plummeted, the close connection between leading psychiatrists and the pharmaceutical industry, once a sign of progress for the profession, is now cited as evidence of corrupt influence." As do Cosgrove and Bursztajn, he points to an ongoing investigation by US Senator Chuck Grassley into ties between drugmakers and academic researchers (see here , here and here).
He poses several questions. First, are psychiatrists in clinical practice receiving more industry money than other specialists? He notes that Lilly lists 25 faculty receiving more than $50 000 in the first three quarters of 2009, and of these, 17 were psychiatrists, although Lilly's investment in psychotropics "may skew this sample...Not surprisingly, companies are paying the specialists most likely to promote or prescribe their products."
What about academic thought leaders and researchers who may influence practice through publications and lectures? In a recent study of med school department chairs, 60 percent reported receiving personal income from industry, usually as a consultant or scientific advisory board member. And 80 percent of faculty reported a departmental relationship with industry, most often for support of continuing medical education. But, he concludes, "there is no published evidence that departments of psychiatry or chairs of these departments receive more or less industry funding than their colleagues in other specialties."
Are academic psychiatrists disclosing more financial interests in publications? "Relative to other professional journals, the major psychiatric journals appear to have comparable standards for disclosing financial interests," he writes. "Based on a review of 397 published reports of clinical trials in four psychiatric journals, a study found 60 percent had industry funding and 47 percent had at least one author reporting a financial relationship. The prevalence of industry funding in general medical journals has been reported to range from 40 percent to 66 percent, with industry support between 34 percent and 43 percent, slightly lower than reported in psychiatry journals." Insel notest the study found articles with reported industry support were nearly five times more likely to report positive results.
Do financial payments to academic leaders influence clinical practice guidelines? He points to a study by Cosgrove and others who reviewed the folks who authored APA guidelines for treating schizophrenia, bipolar disorder, and major depressive disorder, and reported 90 percent had financial ties to industry - and none were disclosed.
Last but not least, is psychiatric practice biased by industry? Insel worries that "aside from the evident success of marketing of specific medications, what is perhaps most worrisome is the relative neglect of effective nonpharmacological interventions such as cognitive-behavioral therapy for mood and anxiety disorders or powerful psychosocial interventions for schizophrenia. Numerous studies have demonstrated the effectiveness of such interventions, and their use has been recommended in the practice guidelines mentioned above, yet they are woefully underused and frequently not reimbursed."
His conclusion? "The greatest threat to an era of improved public health stemming from the productive and ethically sound relationship among academia, industry, and practice is a defiant embrace of the status quo, in which psychiatrists are seen as a leading source of the problem rather than as leaders in finding the solution for financial conflicts of interest."