Authors: James Davies
Dr. Carol Bernstein, the previous president of the APA, referred to this matter when I interviewed her at New York University's Medical School in 2011. When I raised with her Grassley's investigations, her response was unequivocal: “If you're getting money and benefits from doing something, there's going to be tremendous psychological incentive to keep doing that thing, whatever it is, even if it's not science ⦠Brilliant scientists were in bed with the pharmaceutical industry, and I think that they just got corrupted because you get all this money and you get all these perks and you stop thinking objectively. The purpose of pharma, yes, it's to do with research, but it's an industry whose purpose is to make money. So they're going to do whatever they can to make money.”
When I quote this statement to industry-paid psychiatrists, the responses I get are interesting. Many of them acknowledge the dangers, then reassure me that, unlike others, they're on top of it. Others simply shrug as if to say “what else can we doâthe industry is our primary sponsor.”
This position seemed to be close to that offered by Dr. Ian Anderson, the chairperson for the current NICE guidelines in the UK into how depression should be treated throughout the NHS. I interviewed Anderson because he had recently helped alter a clause in the NICE guidelines that I believe can allow pharmaceutical companies to claim that antidepressants have “statistically significant” benefits over placebos, even though the “significant” difference could be as low as a single point on the Hamilton scale. I was concerned that this alteration gave the green light for companies to continue to make inflated public claims about the benefits of antidepressants when in reality the benefits could be completely clinically insignificant.
Toward the end of the interview, I then said, “I must ask you, Dr. Anderson, have you ever received money from the pharmaceutical industry for consultancy, research grants, conferences, honoraria, etc.?”
“Yes, yes, I have,” Anderson replied.
“But you can see how it may appear to people,” I continued. “On one hand you are creating guidelines for how depression should be treated in the NHS, while at the same time you've received pharmaceutical money. Furthermore, you have now controversially removed a threshold that may allow companies to make inflated claims about the power of their drugs. You can see how easy it is to make an argument that there is a bit of a cozy relationship going on here.”
âThere is no perfect solution to individual corruption,” answered Anderson, “if I can put it as strongly as that, since we are all influenced by different things to different degrees. I think one of the problems is that because some of the cutting-edge developments in psychopharmacology are tied in with industry, there is a danger [by severing these ties] of throwing out the baby with the bath water.”
Anderson sits on the fence. But this position would be more acceptable if we knew for certain that industry money did not bias the judgment of its recipients. The problem is that we can't be so certain. For example, there were two recent, separate investigations of what happened when many hospital doctors were given corporate all-expenses-paid trips to seminars at popular vacation sites. Although these doctors said the gifts would never influence them, the investigations revealed that from the period after they had received their invitations, they significantly increased prescribing the promoted drugs.
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In a further study in the
New York Times,
staff analyzed the prescribing habits of psychiatrists in Minnesota. They found that, on average, psychiatrists who received at least $4,500 from makers of newer-generation antipsychotic drugs appeared to write three times as many prescriptions to children for the drugs than psychiatrists who received less money or none.
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Research like this is still scant on the ground, and it only charts the effects on prescribing habits, not on doctors' clinical values, beliefs, and research practices. Nonetheless, it does flag what many people intuitively sense to be the case: that it's harder to retain your independence when you receive money from a company holding a vested interest in your taking a position profitable to them.
4
Given the Grassley investigations discussed above, US readers could be forgiven for thinking that dubious pharmaceutical entanglements are mainly an American problem, and that other countries, like Britain, have escaped the worst excesses of industry involvement. This was certainly what I believed until I started digging more deeply back in the UK. It wasn't long before I realized that regarding transparency laws, Britain is still far behind the United States.
Recent legislation initiated by the Obama administration (called the Physician Payment Sunshine Act) will, as of 2013, oblige all drug and medical device supply manufacturers to track and report all payments made to physicians and teaching hospitals. This move toward greater transparency has been accorded a significant boost since full oversight for the act's implementation has been given to Senator Grassley.
Also, the American Medical Student Association has now set up a system requesting all medical schools to report how many faculty members have acknowledged having these ties.
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Today you can find online which US universities are tightening their policies on drug ties, and find out how many faculty employees have these ties. These moves toward greater transparency are attempts to balance the need for companies to recruit the expertise of doctors with the public's need to know whether a psychiatrist is saying something because it is the best medical advice or because she or he has a financial interest in saying it.
So in the United States there may be a glimmer of light on the horizon, but what about in places like the UK? In 2011, the Association of the British Pharmaceutical Industry's code of practice was updated to include new requirements for companies to declare, as of 2013, payments to doctors for attending medical congresses. These changes are of course welcome. But you also have to read the small print. This code does not include the obligation of companies to disclose payments to doctors for research and development work, including the conduct of clinical trials. Nor does it include a requirement for companies to disclose funding given to doctors for research. Furthermore, the code only requires companies to disclose the total yearly amount paid to all of the doctor-consultants who have provided services.
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Most significant, it does not require companies to
disclose the individual names of these consultants, nor do companies have to disclose the names of doctors who have received speakers' fees or hospitality and sponsorship for attending meetings and conferences.
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In short, if a UK citizen wants to know how much pharmaceutical money his psychiatrist has received this year, short of asking for personal accounts (and good luck with that) he has little hope of ever finding out.
But what about British universities? Under the Freedom of Information Act (2000), I made requests to eight universities chosen at random to disclose whether their psychiatry departments or psychiatric faculty had received payments from the pharmaceutical industry. These universities included Oxford, Cambridge, Manchester, Liverpool, the Institute of Psychiatry (Kings London), University College London, Newcastle, and Edinburgh. So what emerged? Well, two universities declared they hadn't gathered the figures, a third declared (it turns out wrongly) that their psychiatrists had received no money, and I am still awaiting the figure from another university, while the remaining four declared that members of their psychiatry faculty had received pharmaceutical payments. Here is a breakdown.
None of the above universities would disclose their psychiatrists' private industry income for consultancy work, speakers' fees, etc. And in many cases this was simply because the university did not request this information. As Liverpool University put it, psychiatrists “are not required to report individual payments to the University, so we don't hold any information which could be provided in response to this part of the request.”
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But even if universities make a commitment to gathering this information, that is no guarantee that all employees will play ball. For example, one senior British psychiatry department declared to me that their faculty had reported no payments at all, even though there was a responsibility for faculty to do so. Yet after a mere five minutes of searching online, I discovered that at least three of its senior psychiatrists had declared receiving pharmaceutical money in their published research. After I wrote back to the university to point out this discrepancy, a week later another e-mail dropped into my inbox reaffirming curtly: “As we have stated, we are not aware of any academic staff receiving payments from pharmaceutical companies and this would include all academic staff both currently and previously employed by the university.” The phrase “we are not aware” makes it hard not to conclude that these psychiatrists, based at one of the most prestigious departments in the UK, had simply not reported their income to university officials.
The troubling truth is that neither universities nor pharmaceutical companies in the UK are obliged to declare under any kind of legislation the following critical information: the names of individual psychiatrists and what pharmaceutical money they receive for research funding, consultancy work, speakers' fees, hospitality, educational activities, sponsorship, honoraria, and so on.
Without this vital information, we cannot check whether the eye-watering payments Grassley discovered in the United States are also being issued in the UK And this is particularly worrying since we know that payments
are
being made. What we don't know is how much and to whom.
5
Once I left Senator Grassley's office, I headed down the National Mall, that long covering of greenery stretching out from the US Capitol toward the Lincoln Memorial. As I walked close to the shade of the trees, I couldn't shake one of Grassley's final comments from my mind. “Good luck with how your work is received,” he had said with a hint of warning in his voice. It was almost as if he were saying
don't expect an easy ride
. So as I continued on my way toward the memorial, I started recalling some of the responses I'd already received whenever people asked about this book.
Did their responses signal trouble ahead? Mostly the responses were genuinely encouraging. At other times, sure, they were non-committal. But then again, occasionally I did indeed receive reactions that verged on hostile. “Why are you taking on the community?” an older associate asked suspiciously. “Hasn't psychiatry got its house in order since the problems of the 1970s?”
Another man at an academic conference seemed incredulous, telling me that critiquing psychiatry was “a risky business” and asking, “Have you read Freud's
Totem and Taboo?”
(This question, if you don't know the book, implied that my true motive for critiquing psychiatry could be an unconscious desire to take a pop at “authorities.”)
Then there was a gala dinner at my old university where a young cardiologist with black-rimmed glasses and a kindly voice asked me about my research. After giving him a few ins and outs, he said, half-jokingly but also tellingly, “Why, are you a Scientologist?”
Of course I understand these reactions. Medicine is a profession to which we all feel we owe enormous debt and in which we are oftentimes right to trust. So when one of its specialisms is challenged, it would be naïve to expect everyone to take it well. So mostly I just let the more provocative comments slip, treating them as data to be stored rather than as invitations for dispute. After all, I have never felt troubled by authority per se, but only with its abuse. Power itself is neither good nor bad. It is how it is used that matters.
What disturbs me, and I suppose what disturbs us all, is when the powerful, in the name of serving others, begin to use their power to serve themselves. This is what enrages us about political expense scandals, or free press abuses of privacy rights, or good-old-boys networks protecting their own. Call us idealistic or whatever appellation you like, but we are right to feel consternation when people start wielding the privilege of power self-interestedly.
As I continued my way toward the memorial, there was one final comment still on my mindâone that had stood out from all the rest. A psychiatrist I had interviewed early on in this project put it to me frankly: “Don't
you
practice psychotherapy, so don't you
have competing interests? Any critique of psychiatry is surely a goal scored for psychotherapy.” This got me thinking. Psychotherapy and psychiatry, after all, do compete for limited resources, both in the private and public sector. So a book like this, which exposes the weakness of psychiatry, could be potentially seen as inadvertently serving the psychotherapeutic profession (leading to increased employment for people like me). And yet, as sensible as this argument may be, his comment still left me feeling somewhat uneasy.