The pharmaceutical industry is now heavily involved in the organization of research into psychiatric drugs and the dissemination of research findings. This raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda, Moncrieff and her colleagues argue. Drug companies also provide funds for pro drug patient and career groups and address advertising or disease promotion campaigns to the general public. The drug companies exert influence at a political level through lobbying and direct funding of political bodies including drug regulatory agencies.
Why this influence is dangerous the authors argue, is because "psychiatry provides fertile ground for pharmaceutical industry profits because it provides opportunities for expanding definitions of sickness to include more and more areas of social and personal difficulty." The pharmaceutical industry has taken advantage of these expanding definitions by promoting and expanding concepts such as depression, social phobia, attention deficit hyperactivity disorder and psychosis.
Drugs are the central focus of treatment in modern day psychiatry. The vast majority of psychiatric inpatients are prescribed at least one psychoactive drug and many are on several. The same is true for only a slightly smaller proportion of psychiatric outpatients and many more people are prescribed psychoactive drugs, especially antidepressants and benzodiazepines, in General Practice. Furthermore, most patients who are prescribed psychiatric drugs are told to take them for a period of months, and many are told that they will need to take them for many years or even for life.
The easy way in which pharmaceutical companies have been able to expand their business has been the willing help of the medical profession and psychiatrists, in particular.
Routine marketing strategies include the provision of "hospitality" which can vary from the provision of lunchtime refreshments for local meetings to the financing of meals in expensive restaurants or the provision of expenses paid trips to attractive foreign locations for company presentations. When psychiatrists refuse to see company representatives, they may persuade other members of the mental health team to accept hospitality. The provision of small gifts to doctors such as mugs, pens, books and diaries is also endemic. Drug company logos adorn many psychiatrists' offices and are encountered throughout psychiatric hospitals and wards.
It has been repeatedly shown that doctors prescribing practices are influenced by interaction with industry representatives and attendance at Drug Company sponsored events (Wazana, 2000). The fact that the industry invested $15.7 billion in marketing in 2000, and that in the United States there is about one drug rep per 15 doctors, also indicates the importance the industry attaches to its marketing activities (Shaunessy & Slawson, 1996, BMJ).
The drug companies' influence on the medical profession doesn't stop there. However, the industry now underwrites 70% of research into drug treatments (Bodenheimer, 2000). In addition most drug trials in United States are now conducted by commercial research organizations, called Contract Research Organizations. These organizations have emerged recently and hire out their services to drug companies. Thomas Bodenheimer describes a situation in which hundreds of commercial research organizations as well as academic medical centers and other independent non academic sites compete with each other for contracts to do industry funded research. Obviously if the studies do not achieve the desired results, the organization may jeopardize future contracts.
At an individual level, links between academic doctors and the industry are proliferating and include payment for speaking at conferences, consultancy fees, payment for sitting on advisory boards or boards of directors, and holding equity in a company (Boyd & Bero, 2000). A study of published papers found that 34% of primary authors had substantial financial interests in the work they published (Wadman, 1997). In psychiatry the situation may be even worse. In 2000, the New England Journal of Medicine did not have space to print all the financial interests of the authors of a paper on the antidepressant nefazadone and had great difficulty in identifying an academic psychiatrist to write an editorial on the subject who did not have financial ties with companies that make antidepressants (Angell, 2000).
It was also shown recently that 87% of authors of clinical practice guidelines had some interaction with the pharmaceutical industry, and 38% had served as consultants or employees of companies. Despite this, only 4.5% of guidelines contained any declaration of the personal financial interests of authors (Choudhry et al, 2002). This is a cause of concern since guidelines usually command professional respect and have a strong impact on practice.
Evidence suggests this practice is not uncommon, with one study finding that 11% of articles in 6 major peer reviewed journals involved the use of ghost writers (Flanagin, 1998). A recent study of articles on the therapeutics of the antidepressant Sertraline found that over half were produced by a medical information company employed by Pfizer Pharmaceuticals. These articles had higher citation rates and a higher profile within the medical literature than articles written independently.
Advertising in major academic journals provides another mechanism for influencing the message that reaches the public domain. Drug advertisements are now a prominent feature of major British and American psychiatric journals. A typical issue of the American Journal of Psychiatry consisting of about 200 pages of scientific content has approximately 35 pages of drug advertisements and a further 18 pages of advertisements for drug company sponsored "educational" meetings (see for example May 2002 and Jan 2002). Issues of the British Journal of Psychiatry in 2002 had between 5 and 16 pages of advertisements for approximately 100 pages of scientific content.
According to Dr. Thomas R. Insel, of the National Institute of Mental Health, writing in the Journal of the American Medical Association, "Psychiatrists have rarely enjoyed a surplus of public trust. During the past 3 years, public trust in psychiatry has been further undermined with accusations that several leading academic psychiatrists failed to disclose financial conflicts of interest."
According to Loren R. Mosher, M.D., with honors from Harvard Medical School, and Clinical Professor of Psychiatry, School of Medicine, University of California, San Diego, the American Psychiatric Association "is so dependent on pharmaceutical company support that it can not afford to criticize the overuse and misuse of psychotropic drugs. Perhaps more importantly, the APA is unwilling to mandate education of psychiatrists about the seriousness of the short and long-term toxicities and withdrawal reactions from the drugs... In my view American psychiatry has become drug dependent (that is, devoted to pill pushing) at all levels - private practitioners, public system psychiatrists, university faculty and organizationally. What should be the most humanistic medical specialty has become mechanistic, reductionist, tunnel-visioned and dehumanizing. Modern psychiatry has forgotten the Hippocratic principle: Above all, do no harm."
In March 2009, the American Psychiatric Association announced that it would phase out pharmaceutical funding of continuing medical education seminars and meals at its conventions. However, the decision came only after years of controversial exposure of its conflict of interest with the pharmaceutical industry, and the U.S. Senate Finance Committee requesting in July 2008 that the APA provide accounts for all of its pharmaceutical funding. Despite its announcement, within two months, the APA accepted more than $1.7 million in pharmaceutical company funds for its annual conference, held in San Francisco.
The National Alliance on Mental Illness (NAMI), claims to be an advocacy organization for people with "mental illness," but its actions indicate otherwise. The group opposed the black box warnings on antidepressants causing suicide for under 18 year olds in 2004, and black box warnings on ADHD drugs causing heart attack, stroke and sudden death in children in 2006, when their biggest source of funding is drug companies.
The financial conflicts between psychiatrists involved with psychiatry's billing bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-V) Task Forces are under scrutiny and the potential pharmaceutical company influence on what "disorders" are included in the DSM.
A study by Dr. Lisa Cosgrove, Ph.D., from the University of Massachusetts and Harvard Medical School's Dr. Harold Bursztjanin showed that despite the APA instituting a disclosure policy for DSM-V (due out in 2012), only 8 out of 27 members of the DSM Task Force had no industry relationship. "The fact that 70% of the task force members have reported direct industry ties-an increase of 14% over the percentage of DSM-IV task force members who had industry ties-shows that disclosure policies alone...are not enough and that more specific safeguards are needed," stated Dr. Cosgrove. Further, "pharmaceutical companies have a vested interest in the structure and content of DSM, and in how the symptomology is revised."
A 2006 study by Dr. Cosgrove and Sheldon Krimsky, a Tufts University professor, determined how 56% of the170 psychiatrists who worked on the 1994 edition of the DSM (IV) had at least one monetary relationship with a drug maker. The study also found that every one of the "experts" on DSM-IV panels overseeing so-called "mood disorders" (which includes depression) and "schizophrenia/psychotic disorders" had undisclosed financial ties to drug companies. At the time, international sales of drugs to "treat" these conditions were more than $34 billion.
Dr. Irwin Savodnik, an assistant clinical professor of psychiatry at the University of California, Los Angeles, commented at the time: "The very vocabulary of psychiatry is now defined at all levels by the pharmaceutical industry."
Gardiner Harris describers in his article in the New York Times, how the job of a psychiatrist, Dr. Levin, has changed: "Like many of the nation's 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient...like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart."
"I miss the mystery and intrigue of psychotherapy," Levin said. "Now I feel like a good Volkswagen mechanic." He likens his office now to a bus station. In the old days of 45-minute talk sessions, "he knew his patients' inner lives better than he knew his wife's; now, he often cannot remember their names," but the doctor admits, "I had to train myself not to get too interested in their problems."
Harris cites a 2005 government survey which found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.
Part 3 of this article will present evidence that questions the effectiveness claims of psychotropic drugs.
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