Does the pharmaceutical industry influence medicine in general and psychiatry in particular? A direct assessment of physicians’ and researchers’ motivations requires “getting into people’s heads”—an impossible task. Instead, beginning mainly in the 1990s, studies have looked for correlations between interactions or relationships with industry and the outcome of research or patterns of physician prescribing.1 This research yielded four relatively uncontroversial conclusions: (1) Direct-to-physician pharmaceutical marketing works: physicians tend to prescribe promoted products more than standard compounds. (2) Offering samples increases prescriptions. (3) Outcomes of research performed with industry sponsorship usually favor the sponsor. (4) Physician financial relationships with industry are ubiquitous.2
These findings apply to psychiatry as well. For example, Lisa Cosgrove and colleagues researched financial ties to industry for authors of the DSM in 2006 and found that 56 percent of 170 DSM panelists had one or more financial associations with the pharmaceutical industry. Within the Mood Disorders and Schizophrenia and Other Psychotic Disorders groups, 100 percent had industry ties.3 A 2003 analysis of pharmacoeconomic studies of antidepressants found “clear associations” between industry sponsorship and outcomes that favor the sponsor,4 and a review of ten studies comparing clozapine with conventional antipsychotic drugs for treatment-resistant schizophrenia cast doubt on the superiority of clozapine and found an association between a favorable clozapine study outcome and drug company sponsorship of the research.5 Commentaries and newspaper articles have described financial links between drug companies and some mental illness support groups as well as between drug companies and influential physician-researchers.6
These findings and public controversies do not prove that some DSM categories were crafted to advance industry interests, or that psychiatric research results from industry-sponsored trials are always flawed, or that individual psychiatrists’ first loyalties are to drug companies. But together, they support concerns about conflicts of interest in psychiatry.
Unfortunately, psychiatry is not yet doing enough to address these financial conflicts of interest. In 2007, the DSM-V Task Force crafted conflict-of-interest rules for membership in the committees that will write DSM-V.7 Two years after those rules were announced, Cosgrove’s group examined the financial ties of the authors of the American Psychiatric Association’s Clinical Practice Guidelines for treatment of schizophrenia, bipolar disorder, and major depressive disorder. They found that 90 percent of the authors had at least one financial tie to companies whose products were specifically considered or included in the guideline they authored.8 None of these financial relationships were disclosed in the practice guidelines.
Medicine’s—including child/adolescent psychiatry’s—dependence upon industry runs deep, and its influence through marketing and other financial mechanisms is powerful. Alas, the recent rejection by the American Psychiatric Association of stiffer conflict-of-interest rules makes it unlikely that the pharmaceutical industry’s undue influence will diminish anytime soon.9
John Z. Sadler is the Daniel W. Foster Professor of Medical Ethics, professor of psychiatry and clinical sciences, chief of the Division of Ethics and Health Policy in the Department of Clinical Sciences, and chief of the Division of Ethics in the Department of Psychiatry at the University of Texas’s Southwestern Medical Center.
- 1. A. Wazana, “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” Journal of the American Medical Association 283 (2000): 373-80; J.E. Bekelman, Y. Li, and C.P. Gross, “Scope and Impact of Financial Conflicts of Interest in Biomedical Research,” Journal of the American Medical Association 289 (2003): 454-65.↵
- 2. E.G. Campbell et al., “A National Survey of Physician-Industry Relationships,” New England Journal of Medicine 356 (2007): 1742-50.↵
- 3. L. Cosgrove et al., “Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry,” Psychotherapy and Psychosomatics 75 (2006): 154-60.↵
- 4. C.B. Baker et al., “Quantitative Analysis of Sponsorship Bias in Economic Studies of Antidepressants,” British Journal of Psychiatry 183 (2003): 498-506, at 498.↵
- 5. J. Moncrieff, “Clozapine v. Conventional Antipsychotic Drugs for Treatment-Resistant Schizophrenia: A Re-examination,” British Journal of Psychiatry 183 (2003): 161-66.↵
- 6. G. Harris and B. Carey, “Researchers Fail to Reveal Full Drug Pay,” New York Times, June 8, 2008.↵
- 7. A. Kaplan, “DSM-V Controversies,” Psychiatric Times, January 1, 2009.↵
- 8. L. Cosgrove et al., “Conflicts of Interest and Disclosure in the American Psychiatric Association’s Clinical Practice Guidelines,” Psychotherapy and Psychosomatics 78 (2009): 228-32.↵
- 9. W. Goff, “Trust in Shrinks, Shrinks: Psychiatrists Reject Disclosure of Conflict of Interest,” San Diego Health Examiner, June 17, 2010.↵