On August 1, Jeffrey Lieberman, M.D., the current President of the American Psychiatric Association, wrote an open letter to Psychiatry News asking whether is was time for psychiatry to “re-engage with pharma.”
Dr. Lieberman asserts that although there are problems with the way the public perceives drug companies, he thinks it is time for psychiatry to re-evaluate its connections to the industry. He reports on a recent meeting of the American Psychiatric Foundation Corporate Advisory Council with representatives of 14 pharmaceutical companies. He states these representatives “desired re-engagement with physicians and researchers, and most importantly, they understood that all such interactions must be transparent, rigorously monitored, and without conflict of interest.” It is clear from Dr. Lieberman’s post that this desire is mutual.
This article left me confused and not overly confident that much change is underway. Dr. Lieberman does not seem to acknowledge that physicians and the APA share some responsibility for past transgressions. He writes, “Drug companies aren’t held in high esteem by the public” due to their aggressive marketing and high prices. But when he writes about the role of physicians and professional organizations, he states “these problems arose when companies engaged in aggressive marketing practices in the guise of educational activities and paying clinicians and researchers – so–called key opinion leaders – for their advice or research in ways that were perceived as potential conflicts of interests.” (underlining mine). He goes on to state that “Ironically, somehow in this process, our field [psychiatry] became the poster child for physician misbehavior”. We know from his previous statements, that he accuses those who are critical of psychiatry of being “anti-psychiatry“.
I am not clear what he means by re-engage. Dr. Lieberman lauds the guidelines that the APA put in place as “the strictest ethics policy of any professional association for members participating in key programs such as the development of practice guidelines and the revision of DSM.” None of this precludes psychiatrists from collaborating with pharmaceutical companies. Does this “re-engagement” signal an attempt to remove some of these measures? It seems that way since he goes on to state, “Speaking for myself, I believe that the rules and models for informational, educational, and research engagement can and should be developed and applied in ways that allow for our optimal engagement with companies” (underlining mine). I thought the intention of the more recent guidelines was to allow for interaction that reduces conflicts.
Dr. Lieberman’s essay seems short on acknowledging any personal or collective responsibility for the problems that arose in our profession’s interactions with the pharmaceutical industry. This is conveyed in his line about “perceived conflicts of interest.” This implies that the conflicts were not actually present but only appeared that way. This sentiment is further betrayed by his finding irony in psychiatrists becoming the “poster child” for conflicts of interest. The language he uses for the role of the industry is active (they engaged in aggressive marketing) and that of the professions is passive (they were sought after for their advice and expertise).
Dr. Lieberman’s influence in psychiatry cannot be understated. In addition to serving as the current APA President, he is also Chairman of Psychiatry at the Columbia University College of Physicians and Surgeons, Director of the New York State Psychiatric Institute, and Psychiatrist-in-Chief at NewYork Presbyterian Hospital-Columbia University Medical Center. This is one of the most respected medical schools and research institutions in the world. Dr. Lieberman has a long and distinguished research career.
Nowhere in this essay is there any acknowledgement of the harm to patients that arose from these practices.
Nowhere in this essay is there a serious response to those who have offered thoughtful critiques of research conducted in collaboration with the pharmaceutical industry.
During this past week, I was also reading two books, Ben Goldacre’s “Bad Pharma” and “Recovery from Severe Mental Illness” edited by Larry Davidson, Courtenay Harding, and LeRoy Spaniol. These books served as an interesting contrast to Lieberman’s post.
Goldacre explains in great detail the many problems in our current system of drug research and he makes concrete suggestions on how the system could be improved. Lieberman’s essay was lacking in specifics; a call for any academic who worked with Pharma to have free access to all data, an elimination of ghost writers, and a requirement that all trials be made available for review would go at least some way to restoring my own confidence in believing psychiatry was on the right path.
In the Recovery book, I was struck by an essay by John S. Strauss. He was a co-investigator with William Carpenter and John Bartko on a landmark study of long-term outcome for individuals diagnosed with schizophrenia. His essay, “What Is the Reality About Severe Mental Disorder?” is in part a reflection on his experience of conducting a study that led to findings that contradicted the prevailing belief of the time. He trusted the process of research even if it yielded results that were not expected. He also trusted the process of listening to what patients were telling him even if they contradicted prevailing ideas of the nature of mental illness. He struck me as a researcher who was truly engaged with the human beings he was trying to study. He seemed to not only understand but to embrace the complexity of human behavior. This is a level of complexity that is quite hard to characterize with our various rating scales and assessments.
For instance, when describing the variable nature of experiences such as hearing a voice, he writes, “some people described experiences that were ‘sort of like a voice’ in that they could ‘sort of hear it’ but that were also ‘like a thought.'” This led him to suggest that “to understand mental illness and its origins and to create optimal treatments, we might need to think in terms of ‘more or less’ rather than in terms of ‘does this person have this illness or this symptom or not.'” He was amazed and at times angry at the reluctance of colleagues to accept the results of the research. He wonders, “How is it that our field continues to teach and to act as though patients with schizophrenia can’t improve in spite of all (literally all) the data to the contrary?” His candor was refreshing.
Dr. Strauss’ essay led me to wonder what it is about our field that it continues to ignore the role we have played in promoting treatments – fraught with side effects – that are at best mildly or modestly effective in the short run and perhaps even less effective in the long run? The aggressive marketing tactics of the drug companies would not have succeeded if there were not scores of physicians working with them to promote their message.