Leading Psychiatry Journal Declares Conflict Of Interest Important...In 2009

There's a commentary in the March issue of the American Journal of Psychiatry, gingerly addressing the conflict of interest scandals roiling psychiatry--and bringing it to its knees, in the words of Tufts' University's Danny Carlat--and one of the very psychiatric researchers who's been caught in one of the scandals signed on as an author of the piece. That would be A. John Rush, formerly of the University of Texas and now at Duke University's medical school in Singapore. He was outed by Sen. Charles Grassley (R-Iowa) last year for underreporting payouts from pharma companies. Rush was also director of the controversial Texas Medication Algorithm Project, itself a veritable conflict of interest petri dish, pharma influence and a lawsuit brought by the State of Texas against J&J/Janssen.

What's more, the journal's editor Robert Freedman is an author. It's kind of interesting that he would express an interest in conflicts of interest in psych research, since last month I wrote to him to ask him what the journal would do to address undeclared conflicts of interest in a 2005 AJP article and got no answer. Maybe, the fact that the conflicts involved sex between an AstraZeneca researcher and a medical ghostwriter made it too hot to touch, but conflict is conflict.

Even more fun is that the American Psychiatric Association, which publishes the AJP, is itself the subject of Sen. Grassley's ongoing investigation of collusion between pharma and academia, find that in 2006 the APA raked in about $20 million from pharma companies, roughly half of that in the form of advertising in the APA's journals.

Here's the full author list, essentially the editors and editorial board of the journal:

"Robert Freedman (Editor-in-Chief), David A. Lewis (Deputy Editor), Robert Michels (Deputy Editor), Daniel S. Pine (Deputy Editor), Susan K. Schultz (Deputy Editor), Carol A. Tamminga (Deputy Editor), Nancy C. Andreasen, Kathleen T. Brady, David A. Brent, Linda Brzustowicz, Cameron S. Carter, Leon Eisenberg, Howard Goldman, Daniel C. Javitt, Ellen Leibenluft, Jeffrey A. Lieberman, Barbara Milrod, Maria A. Oquendo, Jerrold F. Rosenbaum, A. John Rush, Larry J. Siever, Patricia Suppes, Myrna M. Weissman, Michael D. Roy (Editorial Director, American Journal of Psychiatry), James H. Scully Jr. (Medical Director and CEO, American Psychiatric Association), and Joel Yager (Vice-Chairperson, APA Steering Committee on Practice Guidelines)"

Look, all these conflict of interest scandals represent a tipping point for the psychiatric profession and particularly for psychopharmacology as it's currently researched and practiced. I don't think I even need to explain why that is so. It sounds like the AJP commentators agree with me, at least in part.

"The impact of investigations of conflicts of interest extends beyond their targets and potentially affects the credibility of all psychiatrists. Psychiatry is reexamining its standards and ethical boundaries for interactions with the pharmaceutical industry. Our standards should address not only the conduct of high-profile opinion leaders, but also our responsibility as individual physicians to deliver to our patients the highest-quality evidence-based medicine...."

Basically the piece wanders around the issue, refuses to refer to specific cases, doesn't offer any real solutions, but acknowledges how important the matter has become.

"As individual practitioners, we may feel that we are not affected by public concern over these issues, which often focuses on the acts of a few of our colleagues. Congressional hearings and articles in the New York Times or Boston Globe are far removed from our own practices. But our profession suffers from these episodes and, more important, our patients do as well, because the public and private resources available for the care of our patients depend upon the public perception of the integrity of our profession as a whole. Therefore, each of us has a personal stake and a professional role in the conflict of interest issue. Most of us may never receive a check from a pharmaceutical company. However, by allowing companies to pay for and thus dictate our CME, we support the marketing context in which these acts occur. Our ethical principles as physicians are designed to protect our patients in many ways— primum non nocere, confidentiality, prohibitions of boundary violations. We now need to protect our patients from conflicts of interest in the selection of their treatment. The FDA has already taken leadership in limiting gifts and other inducements that historically were part of drug marketing. Guidelines for the type of pharmaceutical industry support that we each accept for our professional activities, including CME, and how our receipt of this support is shared with our patients when we prescribe drugs need to be more precisely defined by APA and our other professional organizations...."

"More acceptable alternatives—-industry support of education through unrestricted gifts to APA, universities, or other public institutions and journal advertising that resembles sponsorships on public television rather than network prime time commercials—-will likely result in less financial support than we currently receive for our professional activities, because this financial support would no longer be assumed by the companies as part of their marketing strategy. The subsidy that each of us has been receiving is part of what has fueled the excesses that are currently under investigation. Accordingly, in the future it may cost more to attend meetings, to earn CME credits, and to receive journals. Pharmaceutical companies may continue to hire their own speakers and to offer subsidized CME and publications to clinicians through their marketing divisions and private medical education companies. Each of us must acknowledge—-in the choices that we make—-our own responsibility to limit conflicts of interest in order to preserve the integrity of the field that is so important to us all."

I guess this is better than nothing, and it's likely an opening shot in upcoming APA board meetings and whatnot on CME and pharma funding rules and broader questions about conflict of interest. But I find it incredibly childish that the authors should whine about possible decreases in funding and "subsidy" from Big Pharma and possible increased costs of CMEs. The average US psychiatrist makes $180,000 a year and can afford to pay for their own CMEs--and should want to.