Wednesday, June 24, 2009

The APA, Power, and the Exclusion of Dissent

Dr. Doug Bremner has a fascinating but unsettling post about colleagues disinviting him to co-author an academic paper, because they were upset by this blog post he had written.

I have no idea how deep this issue goes, and there is always more to everything than meets the eye, but I do have my own recent personal experience of being shunned by the academic establishment, and I thought this would be an opportune time to tell that story.

As some of you know, in 2008 I was elected by those liberal Massachusetts psychiatrists to be one of four state representatives to the American Psychiatric Association. This means that I attend monthly meetings of the council of the Massachusetts Psychiatric Society, as well as quarterly meetings of the New England region (called “Area 1”) of the APA.

One of the things that happens when you get into a leadership position in a big organization is that you find out that there are dozens of committees and task forces and this is where all the real work takes place. Sometimes you get appointed by a powerful person, like former president Nada Stotland, who appointed me to a couple of committees, one of which was the task force leading to the APA’s decision to phase out industry supported CME at the annual meeting. Other times, you end up in committees via informal protocol.

Thus, for example, if you are on one of the APA Area councils (which I am), you may be invited to serve as an “Area council liaison” to a given committee. One of these committees is the “APA Steering Committee on Practice Guidelines.” As you can see here
, this committee is composed of about 24 people, seven of whom are liaisons from each of the seven Areas of the APA. It’s an important committee, because it is in charge of reviewing and approving any new practice guidelines. The practice guidelines then filter their way out into the community of mental health professionals and influence how patients are treated.

Recently, my Canadian colleague Joseph Berger announced that at some point over the next year, he would be replaced on the Area 1 committee by one of his colleague, and that therefore his slot on the Practice Guidelines Committee would be open. I expressed an interest in it, because sifting through practice guidelines and the research upon which they are based is basically what I do for a living as the editor of The Carlat Psychiatry Report. Dr. Berger was happy to find an eager volunteer, and he graciously made some email introductions to the various players involved.

Here’s where things began to go sour. I heard through this or that grapevine that some of the practice guidelines committee members were concerned about my “conflicts of interest.” I was surprised, since a recent study had found that 90% of members of three major work groups of the committee had conflicts of interests (COIs) with pharmaceutical companies.

Obviously, COIs per se are not forbidden. But perhaps I represented a special case, because, while I have no drug industry relationships, I publish what might be considered a competing publication. Perhaps they were concerned that I would spy on their process to improve The Carlat Psychiatry Report.

But I found out that the concern was about something else entirely. Somebody on the committee said that I had embarrassed members of the DSM-V committee by publishing something on my blog. I wracked my brain for what this could be. Finally, while on my morning jog, it came to me.

Back in October of 2008, I posted this article reviewing the breaking news about the extent of Dr. Charles Nemeroff’s undisclosed conflicts of interest at Emory. There were almost 30 comments on that posting, and one of the commenters, who was anonymous, left the following comment:

“A reminder that a further feature of pseudoacademic pseudopsychiatry is that the group noted by Dr. Gitlow defines the diagnoses we use, and defines them of course in a way that not only maximizes drug treatment, but shapes them according to the interests of particular drug corporations. One recent example only: Dr. Schatzberg has been campaigning at the APA DSM V committee meetings to dilute the criteria for major depression with psychotic features, so that the drug his company manufactures for the condition might attain broader use.
October 5, 2008 8:17 PM”

I confess that I don’t scrutinize every single one of the comments that are left on my blog. I publish just about any comment that comes in, as long as it is not profane or completely off-topic, and I make no guarantee that comments are accurate. I also often disagree vehemently with commenters. That’s called healthy debate.

At any rate, somebody in the higher APA echelons saw this comment, and I was told that it inaccurate, and that my publishing it reflected poorly on both myself and on the APA.
While under no legal obligation to do so, in order to soothe hurt feelings, I decided to delete the comment, and announced the fact in this post.

Well, no good deed goes unpunished, and somebody on the practice guidelines committee is still sore about the incident and believes this shows I am a loose cannon and that my presence would inhibit free discussion on the guidelines committee.

Actualy, if anything, I would think that the presence of someone who has been at the forefront of ethics reform efforts would help to legitimize and improve the APA guidelines process.

The episode is profoundly disappointing to me personally, because I have a particular interest in making the currently dry guidelines more readable and therefore more likely to be read by practicing psychiatrists.

But it is also disappointing to me as a member of the APA, because I would have thought that the tent of the organization is big enough to tolerate the rubbing of shoulders between people who may disagree strongly on some topics. Psychiatrists, of all professionals, should know that avoiding confrontation is rarely the road toward health, whether psychological or organizational.


Doug Bremner said...

Thanks for writing this, Dan. It seems that psychiatry is particularly egregious in this department. This blog has been a great forum for open vigorous debate, the way it should be. God forbid someone who has actually spent as much time as you have for your Carlat Report reading the primary literature and making an unbiased evidence based judgment about relative efficacy of different medications should be on a practice guidelines committee. That is probably the real reason they don't want you on, is because you have a brain and use it and can't be coerced.

Anonymous said...

You have so much to learn. There's always a reason. If not this then something else would be found.

Anonymous said...

I don't think your colleagues fear competition from the Carlat Report or a vigorous debate fueled by good will. I think your colleagues fear you'll use such opportunities as fishing trips for content for post blogs on this site. While COI is a real issue, there is often a rush to judgment on-line, and a lack of due process before reputations are slandered.

Gina Pera said...

Holy smokes. That stinks, Dr. C.

Am I surprised, though? Absolutely not. In fact, I would expect it more than not, given the delicacy of some of these egos -- not to mention the control-freakiness.

Better these types serve on committees than commit bullying atrocities on innocent clients. But overall, better for them to just get over themselves and develop, what do you call it...ego strength?

Gina Pera said...

P.S. Truly, some of these guys just don't get out much, do they? The idea that they would expect you to control (in their favor, of course) the content of blog posts???

CL Psych said...

One anon commenter:
"I don't think your colleagues fear competition from the Carlat Report or a vigorous debate fueled by good will. I think your colleagues fear you'll use such opportunities as fishing trips for content for post blogs on this site. While COI is a real issue, there is often a rush to judgment on-line, and a lack of due process before reputations are slandered."

Your point would be believable if Carlat had actually taken material from a meeting then written slanderous material on his site based upon his observations in the meeting. But it appears he was snubbed because of a comment on his blog. Carlat might be the most level-headed even-handed blogger around when it comes to mental health. Look at my site, Bremner's site, Furious Seasons, Bernard Carroll's occasional posts on Health Care Renewal and you'll see what I mean. Perhaps only PsychCentral can lay claim to being as evenhanded as Carlat's site. It's obvious Carlat doesn't like that much CME content is blatantly biased. He doesn't like science that is twisted for commercial gain, at the expense of patient well-being. But can you really provide any evidence that he is a slanderer or someone who takes confidential material from meetings and plasters it all over the internet?

Treatment guidelines have seemingly become very influential and it would make sense to have someone with Carlat's credentials involved with developing said guidelines. Would you rather have a guy who lacks pharma funding and runs a well-respected newsletter helping to devise guidelines, or would you prefer a run of the mill, heavily conflicted key opinion leader?

Anonymous said...


I personally know the influence of power and exclusion of dissenting opinion.

I am the ex-FDA clinical pharmacologist who spoke at yesterday's FDA transparency meeting. I worked on psychiatry drugs for the last 7 years and was fired for whistleblowing to Senator Grassley among others. I am currently appealing this.

I knew FDA had problems but didn't begin to realize the extent until I overheard a medical division director and a more senior manager discussing how they were going to get Wayne Fenton who was Chairman of the Psychopharmacologic Drug Advisory Committee to direct the discussion and sway the vote. Fortunately reviewers were able to outflank this manuver and the drug was dropped by the company for safety reasons.

Two weeks ago I spoke to several of my ex-colleagues who review Psych drugs and I was asked to continue to speak out. I know as government employees they are effectively muzzled and I am still muzzled as to proprietary and commercial trade secret information.

I worked on several of the last few new antipsychotics reviews including a couple that were turned down or the review cycle delayed. I've seen how the reviews and review process is manipulated and know that I can no longer trust other reviewers reviews to be truthful.

As I said yesterday reviewers are so scared that they self censor.

I believe that the only answer is that all the raw data and other materials submitted must be released on approval or turndown.

Even so clinicians do not have the time to go through the clinical data much less the skills to go through mathematical modeling, drug metabolism, enzymology, animal, and chemistry data that even FDA reviewers who are specialists and have years of experience have trouble going through. However I believe it is the only chance. Hopefully someone either a nonprofit, major law firms, or payers will start groups to go through this material. It's the only way to kept things honest.

Ron Kavanagh

localdoc said...

wow, it sucks to have people make judgments about you and your work, and your motives, based on bias, half-truths or misinterpretation of your writing...

hmmm... sorta makes you wonder how all those academic psychiatrists whose integrity is being questioned here and elsewhere in the blogosphere on a daily basis must feel, doesn't it?

Doug Cranmer said...

Look, you have a widely read public blog that is critical of certain elements of the psychiatric profession. So of course there is a conflict of interest.

How comfortable do you think committee members would be working with you knowing anything you don't agree with is fodder for your blog? Or could provide a tip off to any of the other blogs critical of the psychiatric profession?

It's a matter of eating your cake and having it, too.

Unknown said...

I'm rather amazed by the widespread opinion that having a blog (well, a direct line to several members of the public at large who wish to read your thoughts; could be a mailing list or twitter, doesn't matter) makes you different (or a liability). Don't they realize that this is the future?

Everyone wants to be heard, and many people want to hear those who are highly educated and deeply involved in their field of study. I guess the difference is that it's harder to cover up injustice with the official party line when you can't cut off someone from the media.

Anonymous said...

WD is right. If you want to be part of the "club" you need to go back to being Doctor Drug Rep and be happy with your role (and money). Don't make waves.

Doug Cranmer said...

Which is something that should change. And it's just not going to change over night. My point was about the state of things right now.

I think keep doing what you're doing if you feel it's right thing, Dr C. And I believe it is.

You certainly have my respect for your work. And I'm sure a great many others do as well.

Gina Pera said...

Oh boy. Well said, localdoc:

wow, it sucks to have people make judgments about you and your work, and your motives, based on bias, half-truths or misinterpretation of your writing...

hmmm... sorta makes you wonder how all those academic psychiatrists whose integrity is being questioned here and elsewhere in the blogosphere on a daily basis must feel, doesn't it?

skillsnotpills said...

When will you get it, people? Having been screwed by the established psychiatrists in various clinical settings in my career, the good ol' boy and gal network is entrenched and has no other agenda than self serving and controlling the field and the population they allegedly treat.

Regarding a lot of the commenters, I gather you report the tip of the iceberg, and then go on your merry ways as you have not been too harmed thus far, for the most part of what I have read. The APA is not an organization that a true invested psychiatrist should be proud to be a member these past ten years or more. Not with the character of leaders elected as presidents since Harold Eist served. If that insults anyone, sorry, but no retraction is forthcoming!

Anyone here been a REAL whistleblower? Then you know what it is really about. Be forced out of a job, your home, and be ostracized by people who previously not only never said negative things but actually spent time with you. But, at the end of the day, you have to live with yourself and face those you respect and see as true peers and supports. Whistleblowing is beyond a thankless job, and at this point of my life, I do for myself and will not wait around for the masses to figure it out, because as George Carlin so appropriately said it, "the public sucks, screw hope." So, for those reading here, I hope you do what is right and don't hold your breath waiting for those who should support you to do so, because the majority of them don't have a conscience until proven otherwise. Believe me when I say from repeated experiences, most don't!

Here is an adage I doubt too many can appreciate: I'd rather be vilified for doing what is right than be glorified for doing what is wrong.

Chomp on that a bit!

Thank you again for notifying me of this post, Dr Carlat.

Dan said...

As with the FDA acceptance or rejection of pharmaceuticals, the DSM process should not be secretive as well.

The Diagnostics and Statistical Manual (DSM) of the American Psychiatric Association (APA) has a lot of power with what is annotated in this manual., including determining reimbursements and treatment regimens as well as assessment criteria for those suspected to have a mental disorder, as defined by the task force responsible for the creation of the DSM under the direction of the APA.

I’m still trying to figure out how exactly the DSM folks have the ability to add and delete what were previously determined to be mental disorders? Is this interior decorating, or medicine?

I’m a novice, and I think highly of any mental health expert who challenge and criticizes the formation of the DSM. They realize that there is much at stake here, and that life is not a popularity contest:

The Diagnostics and Statistical Manual (DSM), the Shrink's bible, has been around for over 50 years. Within this manual, there are now possibly nearly 300 mental disorders.

The latest DSM, the DSM IV, was made available in 1994. The next DSM V expects to have its first draft finished by the end of 2010- and those involved with its creation speculate that the DSM V be published in 2012.

As a thorough dictionary of suspected mental illnesses, many redefined or recognized diagnoses are added to this manual with each edition often. This is particularly the case if medicinal therapy exists as a treatment option for certain mental illnesses.

On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s.

Its purpose, this manual, is to assist mental health professionals to diagnose and classify mental disorders.

Published and designed by the American Psychiatric Association (APA), the DSM is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement.

The DSM is organized partially by the following:

I- Mental disorders
II- mental conditions
III- Physical disorders/syndromes, medical conditions (co-morbidity)
IV- Mental disorder suspected etiology
V- Pediatric assessments

The APA has historically directed the creation of each edition of the DSM, and assigns selected task force members to create this manual. This situation has proven to be controversial.

The next DSM involves 27 people. About 80 percent of these individuals are male, and less than 5 members are not medical doctors. Most have had relationships with the NIH, and about 25 percent of these task force members have had relationships with the WHO.

Historically, at least a third of task force members have had, or do, have often monetary pharmaceutical industry ties in some way. Presently, greater than fifty percent of the task members have pharmaceutical industry ties.

This makes sense, as one considers that about one third of the APAs total financing is from the pharmaceutical industry.

The APA required this task force for the next DSM edition to sign non-disclosure agreements- which is rather absurd and pointless. Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.

The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity. This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at a concerning rate- with very young children in particular.

Dan Abshear

Anonymous said...

I like the idea of an external peer review of whatever the DSM task force comes up with in their closed, and secretive, deliberations. I am also long in the tooth and I (fondly) recall DSM-I and II. If memory serves me correctly (and it may not), I think these versions of the DSM were about 30 to 40 pages long. And they seemed to work at least as well as our current "War and Peace" monographs. Jeez!