Psychiatry's Leadership is Getting Real

I believe it is important to give credit where credit is due. The current issue of the American Journal of Psychiatry features a commentary entitled "Conflict of Interest--An Issue for Every Psychiatrist." The article is authored by all 23 editors and editorial board members of the journal, with additional contributions from three others. This is a who's who of psychiatry, including Jerry Rosenbaum, the psychiatry chairman at Mass General, Robert Freedman, the Editor-in-Chief of the journal, Nancy Andreason, winner of the National Medal of Science, and many others.

Furious Seasons criticizes the piece for being too vague and offering no specific solutions, but I see it differently. The authors do a good job of laying out the major issues related to conflicts of interest in psychiatry, and in fact they do have some specific recommendations:

"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."

It seems to me they are recommending that industry money be disconnected from specific educational programs, and instead should be donated to medical societies and universities into pools of money that can be used to fund any education, even programs that don't serve the specific promotional aims of the funders. If instituted, this would represent a huge change in business as usual.

Perhaps they are vague in not naming names--but when they reference "congressional hearings and articles in the New York Times or Boston Globe" it's pretty obvious who they are talking about. Look, this is a guild, folks, and you don't smear members of your own guild (unless you are as reckless as I am!). I think it is remarkable that these 26 authors were able to agree on a document that is pretty critical of industry's coziness with psychiatry--especially since many of them are direct beneficiaries of industry's largesse.

On another note, while the Furious Seasons post quoted me accurately in the opening paragraph, it was pulled from a different context--namely a December 1 posting in which I was responding to recent revelations on serious conflicts of interest regarding Dr. Biederman and Dr. Goodwin. The comment was meant to point out that if psychiatry were a patient, it would need ICU treatment to pull it out of its ethical crisis. The fact that the leaders in the field could have written this AJP commentary shows that the patient is looking much healthier.

Conflict of Interest in High Places: the American Journal of Psychiatry

It's tough being the editor of a major medical journal these days. You are under constant pressure to fill your pages with high quality research, and much of this is funded by drug companies. Company-funded research is fine, and often leads to important drug discoveries. The problem is that the editors in charge of accepting articles often have their own drug industry ties, making it hard to trust the integrity of the journal content.

The New England Journal of Medicine has been embroiled in these issues for years. The current editor, Dr. Jeffrey Drazen, initially had ties to about 20 drug companies when he took over from Marcia Angell, but he has since severed those ties, and has become an important watchdog of excessive industry influence in medicine.

Unfortunately, our major psychiatric journal, the American Journal of Psychiatry, has decided to take the low road, heading back into the land of conflict of interest. Each January, the journal publishes the financial disclosures of its main editors. You can read the latest disclosures here. The editor in chief, Robert Freedman, M.D., who disclosed no competing interests last year, now discloses that he serves as an "unpaid co-investigator ... for investigations sponsored by pharmaceutical companies that are developing new drugs for patients based on his research findings."

I nearly jumped out of my seat when I read that, because this is the same editor who took the unusual step of writing an editorial criticizing an accepted article in December 2006 issue. Freedman critiqued an article by Rosenheck that presented data showing that the old antipsychotic Trilafon was more cost-effective than newer atypicals. At the end of that editorial, Freedman said he had no competing interests. Maybe that's true--perhaps he did not begin his "unpaid" investigations with companies until after he wrote the editorial. However, it seems likely that he knew at that time that he might be entering into those relationships, because he has been conducting the research on antipsychotics for many years.

What about the "unpaid" nature of his work with companies? Does this mitigate the nature of his competing interests? Of course not; Freedman co-owns a patent for a promising molecular target of new antipsychotic drugs (see this article for background), and stands to benefit hugely, either financially, or in terms of career advancement, if this target pans out as an effective treatment for schizophrenia.

Don't get me wrong: I think it's great that Dr. Freedman is doing important research and I hope it leads to effective new treatments. But is he the right man to be at the helm of the major American psychiatric journal? Certainly not. We need an editor with no competing interests, whether those interests are related to financial incentives or career incentives.

By the way, I e-mailed Dr. Freedman about my concerns and he responded with the following explanation which I found perplexing:

"My research concerns the development of new treatments for schizophrenia, for which I am funded by NIH and VA research grants. NIH and the VA funded the development of the molecule that I currently am working on. However, in the course of developing new drugs, I may need to interact with a pharmaceutical company if it has discovered a more promising molecule for the targets that my research group has identified. Although that has not happened, I want our readers to be aware that it could possibly happen. It is a disclosure in advance of any transaction that might subsequently require disclosure, so that readers can assess the issue in prospect."

That's a mind-bender! In this month's issue of his journal, he states that he "serves" as an investigator for studies sponsored by drug companies. But in his response to my question, he retracts that disclosure, saying that, in fact, he has not worked with drug companies, and does not now, but that he might in the future.

I, for one, am confused. I look forward to what Dr. Freedman has to say in his 2009 disclosures!