“Culture of Influence” Eroding Public Trust in Psychiatrists
Public trust in psychiatry is being eroded by the specialty’s real and perceived ties to the pharmaceutical industry, says a leading psychiatrist
In an editorial in this week’s issue of the Journal of the American Medical Association, Thomas Insel, MD, director of the National Institute of Mental Health (NIMH), highlights the entrenched relationship between psychiatry and big pharma that has resulted in what he describes as a “culture of influence.”
According to Dr. Insel “psychiatrists have rarely enjoyed a surplus of public trust.” However, recent events have further eroded this tenuous relationship.
In his editorial Dr. Insel details recent events that have served to further undermine public trust in psychiatry — foremost among them accusations that several leading academic psychiatrists, including Charles Nemeroff, MD, PhD, from Emory University in Atlanta, Georgia, were accused of failing to accurately disclose payments from drug companies.
“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,” he writes.
Dr. Insel notes that these allegations have had major effects, including more rigorous disclosure requirements in many US universities and major initiatives by the National Institutes of Health to tighten restrictions on outside income and overhaul its regulations on financial conflicts of interest, which were originally adopted in 1995.
He also points out that the NIMH has launched an internal review system to “detect potential problems with the management of financial conflicts of interest and has implemented changes to minimize possible bias in its funded studies.”
However, Dr. Insel notes that the largest effect of these events has been to bring psychiatrists’ integrity into question.
Research shows that at least in the state of Vermont, which requires public disclosure of all pharmaceutical industry payments to physicians and has comparative data across all medical specialties, psychiatrists receive the lion’s share.
He also notes that a number of pharmaceutical companies are now voluntarily publicly posting payments to physicians.
Although state and pharmaceutical company registries largely reflect payments to individual physicians, Dr. Insel notes that a major concern is whether academic leaders and researchers who are in a position to influence practice through their academic work may be similarly unduly influenced by drug company money.
He notes that a recent study of all medical school department chairs shows 60% reported receiving personal income from industry and that 80% of faculty reported a relationship with industry.
To date, he writes, there are no data to show whether departments of psychiatry or their chairs receive more or less industry funding than their counterparts in other specialties.
Dr. Insel also points out that a recent review of 20 work groups members who authored American Psychiatric Association guidelines for the treatment of schizophrenia, bipolar disorder, and major depressive disorder showed 90% had industry ties but none was disclosed.
In contrast, a similar review of 192 authors of 44 clinical practice guidelines across a wide range of common adult disease showed 87% had some form of industry involvement but disclosures were only included in 2 cases.
“…it is difficult to conclude that academic psychiatrists receive more or disclose less than their colleagues in other areas of medicine. But what is clear is that current pharmaceutical industry investment in academic psychiatry is prevalent,” he writes.
Nonpharmacologic Treatments Woefully Underused
But perhaps the most pressing question, says Dr. Insel, is whether psychiatric practice is biased by industry. He notes that psychiatric treatments have become largely pharmacologic, with antidepressants and antipsychotics representing 2 of the top 5 drug classes sold in the United States and sales that ran more than $25 billion in 2008.
Although many generic medications have been shown to be effective, Dr. Insel points out that more expensive, brand name drugs continue to hold most of the market share.
Most “worrisome,” says Dr. Insel, is the relative neglect of effective nonpharmacologic interventions, including cognitive behavioral therapy and psychosocial interventions.
“Numerous studies have shown efficacy of such interventions, and their use has been recommended in the practice guidelines … but they are woefully underused and frequently not reimbursed,” he notes.
Although bias is not unique to psychiatry, writes Dr. Insel, this fact alone “doesn’t diminish the severity of the problem.”
Psychiatrists, he adds, have an opportunity to take the lead and set new standards for interactions between all medical disciplines and industry and develop a “culture of transparency.”
“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,” Dr. Insel writes.
Dr. Insel has disclosed no relevant financial relationships.