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Psychiatry's Many Conflicts of Interest

A review of "Psychiatry Under the Influence"

Source: Pitac/iStock/Thinkstock

“Our use of psychiatric medications could be said to range from womb to grave,” Robert Whitaker and Lisa Cosgrove observe accurately and chillingly in their coauthored study Psychiatry Under the Influence, a powerful, important book on the field’s many conflicts of interest. “An increasing number of infants born today are exposed to an antidepressant in utero, and psychiatric drugs are regularly given to the elderly in nursing homes to individuals without psychiatric disorders. As such, our society has a compelling interest in the investigation that is at the heart of this book.”

Indeed it has, and the authors set out the high stakes for public and mental health by undertaking a rigorous investigation into the ethical and financial conflicts facing all aspects of academic and clinical psychiatry, from its widespread reliance on industry funding to its well-documented struggle to enforce strict and reliable thresholds for dozens of disorders added to its official diagnostic manual, the DSM: “At every step,” the authors conclude, “we have seen the integrity of the scientific process compromised by two economies of influence: psychiatry’s ‘improper dependency’ on the pharmaceutical industry, and psychiatry’s own guild interests.”

Cosgrove, PLoS Med (2012); used with permission.
Source: Cosgrove, PLoS Med (2012); used with permission.

Both sets of conflicts are examined in such startling detail that at one point we’re following the precise amounts of money key “thought leaders” were reimbursed for their flights, exactly where they stayed during well-remunerated symposia, and, far more critical, what percentage of them serving on DSM task forces and committees had ties to industry (an overall increase from 57 percent in the mid 1990s to 69 percent for DSM-5, with 100% involvement in several subfields). We also learn which drug companies paid handsomely for the experts' advocacy and support, to the point of ghostwriting articles for them. These would arrive with a cover sheet reminding that it should be tossed before the work in question was submitted for publication. The numbers are detailed to the nearest dollar. The most egregious cases are named to underscore veracity, and as Lawrence Lessig, Furman Professor of Law and Leadership at Harvard, notes in his foreword to the book, the results are both “incredibly compelling” and depressingly convincing.

Stemming from research undertaken at Harvard's Edmond J. Safra Center for Ethics, specifically on "institutional corruption," Psychiatry Under the Influence appeared almost a year ago, yet its continued importance to everything from debates about biomarkers to concern about healthcare costs in the U.S. presidential race ensures its relevance for years to come. Whitaker and Cosgrove—respectively an award-winning investigative journalist and author of Anatomy of an Epidemic and Mad in America; and a clinical psychologist and professor at the University of Massachusetts, Boston, co-author also of The Ethics of Pharmaceutical Industry Influence in Medicine and coeditor of Bias in Psychiatric Diagnosis—unearthed some of their evidence via the University of California’s Drug Industry Document Archive and requests to the Project on Government Oversight.

APA annual financial reports, 1980-2012; used with permission.
Source: APA annual financial reports, 1980-2012; used with permission.

Certainly, no one reading Psychiatry Under the Influence with the necessary care could fail to note an exacting use of data to support what are strong and, for many, unpalatable contentions: that the APA has largely failed to tackle its growing reliance on industry funding for grants, fellowships, and programs, with revenue instead rising from $11.3 million in 2000 for sponsored meetings alone to, by 2008, a total of $65.3 million in general revenue. Indeed, after efforts that year to phase out industry-support symposia, the organization has in recent years returned to them, presenting their funding as both attractive and inevitable.

Warnings about such ties (including by insiders) have also been sounded. As APA speaker Fred Gottlieb noted in one 1985 report on research protocols, regarding what he called “the millions of dollars of drug house money we receive annually from advertising and commercial exhibitions and for awarded lectureships and social functions”: “I do not suggest that either they or we are evil folks. But I continue to believe that accepting such money is, in the long run, inimical to our independent functioning” (qtd. 37; his emphasis).

Meanwhile, based on a raft of increasingly disturbing evidence, the APA has in Whitaker and Cosgrove’s assessment failed to protect the public from undue harm, including from medical treatments whose safety and efficacy were repeatedly overstated, when the actual literature pointed over and again to failing long-term outcomes, notably after three years of pharmacological treatment, an interval that many drug trials would not be designed to study.

Psychiatry Under the Influence is packed with vitally important information about a range of interlocking crises and concerns, from psychiatry’s compromises over objective data to its struggle to enforce strict and reliable thresholds for disorders added by the dozen to its official diagnostic manual, the DSM. Always starting from the conclusions to the drug trials and studies themselves, including mismatches between abstracts and main arguments in some of the leading journals, Whitaker and Cosgrove’s contentions about organized or institutional psychiatry are best summed up by this paragraph:

The psychiatric literature is flawed in numerous ways. Academic psychiatrists regularly lent their names to ghostwritten papers. Trial data may have been “mined” in order to report a positive funding for a drug that failed to show efficacy on a primary outcome measure. Conclusions announced in abstracts may be discordant with the data in the body of the article. Reviews of data submitted to the FDA reveal a different profile of risks and benefits for a particular drug than is found in the published articles. Poor outcomes for medicated patients in long-term studies have not been communicated to the public. And so on.

The cumulative effect of such corrupted data, they note, is “a medical literature that exaggerates the benefits of psychiatric medications and underestimates their risk,” all the while making it “impossible for psychiatrists and other physicians to provide their patients with sufficient information to ‘make an intelligent choice.’ The published ‘evidence base’ is tainted, and thus all of society ends up somewhat in the dark.”

Whitaker and Cosgrove build their case for such “institutional corruption” with painstaking care, covering both the recent and distant history of psychiatric diagnoses; major and still-controversial additions to the DSM, and, in particular, how the APA, “through its expanded criteria for diagnosing mental disorders, … helped create a much larger market for psychiatric medications …. from approximately $800 million in 1987 to more than $35 billion in 2010.” The fact that “297 or more diagnoses were listed in DSM-IV led,” they note, to “an obvious question: Could there really be that many discrete mental disorders?” Yet the diagnoses themselves were “wrapped in the cloak of medical diseases, even as the ‘limitations of the categorical approach’ statement in DSM-IV told of boundary lines being arbitrarily drawn.”

We learn that many years after DSM-III appeared in 1980, and five years after task force chair Robert Spitzer claimed misleadingly that its criteria “would be ‘suggested’ only, [with] any clinician … free to use them or ignore them as he saw fit,” “most of the 265 disorders [it listed] had yet to be validated” (qtd. 22). Meanwhile, concerned voices such as that of Yale Medical School psychiatrist James Phillips complained that “the startling failure of research to validate the DSM categories of DSM-III and DSM-IV ha[d] led to a conceptual crisis in our nosology” (qtd. 60).

We witness Ronald Pies, editor of Psychiatric Times, dismissing talk of “the ‘chemical imbalance notion as always a kind of urban legend” even as a future president to the APA (Nada Stotland) was busy contending that antidepressants “restore brain chemistry to normal” and a leading psychiatrist for the National Alliance for the Mentally Ill (Peter Weiden) argued that older antipsychotic medication “correct[s] brain chemistry,” while newer treatments “seem to do a better job of balancing all of the brain chemicals, including dopamine and serotonin” (qtd. 59, 54, 53).

Psychiatry Under the Influence also takes readers through an array of scandals attached to SSRI antidepressants and atypical antipsychotics, including the well-documented problems they present over tapering and drug-induced suicidality. The book describes both the rise and the expanded marketing of ADHD; the redefining of depression as inseparable from normal and event-related sadness; and data indicating that antidepressant-induced changes in the brain made patients more vulnerable biologically to depression.

Whitaker and Cosgrove write searchingly and persuasively about the individual and social harms that accrue from patients’ and doctors’ inability to make informed choices about our most widely prescribed medication. They detail the betrayal of public trust that arises “when people who have been told they suffer from a chemical imbalance subsequently discover that isn’t so.” And they offer several “prescriptions for reform,” including that the APA move to requiring that its officers be free from drug-industry ties and institute a policy barring CME [Continuing Medical Education] offerings funded by industry. The organization might also “decide that the board members of its two philanthropic arms—the American Psychiatric Institute for Research (APIRE) and the American Psychiatric Foundation—could not have such ties to industry.”

Whitaker and Cosgrove recognize that the disclosure of such conflicts-of-interest won't in itself be a solution to ongoing bias and that many structural obstacles to reform remain, including just how reliant the APA has become on drug company funding. Even so, they share with medical scholar Sunita Sah and physician Adrian Faugh Berman a quiet optimism that “if greater academic prestige accrues to distant rather than close relationships with industry, a new social norm may emerge that promotes care and scientific integrity” (qtd. 202).

We can only hope that it does. The point made over and again in Psychiatry Under the Influence is that we mustn’t be content simply to interpret the world of psychiatry; in all ways possible, we must strive to change it. As Lawrence Lessig comments astutely in his foreword to the book, “Whether or not there was an excuse for what broad swaths of psychiatry became, there can be little excuse for leaving it untouched now.”

Psychiatry Under the Influence can be purchased online here. Follow me on Twitter @christophlane