It’s Not About Goodwin. It’s About Disclosure.

The Frederick Goodwin/Infinite Mind case has become one of the defining controversies for a crucially important health policy issue. Some of us have become hot-headed in our comments, largely because this is something we feel so passionately about. So, in this post, I’ll be keeping my cool, and will pluck some of the significant issues from the morass of accusations into which this debate has degenerated.

1. This is a debate about disclosure of potential conflicts of interest, and not a debate about Dr. Goodwin’s scientific views or his academic integrity.

Let’s not get sidetracked into a discussion of whether antidepressants do or do not cause suicidality. On "Prozac Nation Revisited," it was clear that Dr. Goodwin and his guests believed that this danger has been exaggerated. I happen to agree. But that’s not the issue here.

Nor is this about Dr. Goodwin’s scientific work over the years, which has been excellent. His writings have always struck me as scientifically fair and balanced, including his industry-sponsored CME articles, which is a tall order, given how difficult it is to keep MECCs from sweetening CME with pro-sponsor messages.

No, this debate is specifically about how, when, and where academics should disclose potential conflicts of interest with the pharmaceutical industry. And I believe that "The Infinite Mind" should have disclosed to the listeners, at the beginning of each program, all potential conflicts of interests relevant to the topic of that program.

2. I do not believe that the mere disclosure of conflicts of interest is an admission of “guilt” or “bias,” but audience-members need to be informed so they can judge for themselves.

If an academic takes money from the drug industry and then educates physicians or the public about drugs, this is, inherently, a potential conflict of interest. Here is the conflict: on one hand, the speaker has an interest in providing accurate, useful, and unbiased information to the audience. But on the other hand, the speaker has an interest in maintaining the flow of money from the company, and companies are paying out the money to improve sales.

Speakers with such conflicts may do one of three things. First, they may knowingly bias the talk in favor of the sponsor’s drug. Second, they may unconsciously bias the presentation. Or third, they may not bias the talk in any way at all.

The audience has no way of knowing what goes on in the mind of the speaker, so they have no way of knowing whether they can trust what he or she has to say. In my opinion, the best way to resolve this problem is for doctors to stop accepting money from drug companies for promotional activities. However, at a minimum, listeners needs to know what the potential conflicts are, so they can be on the alert for potential bias.

3. Many have pointed out that “we all have biases,” so why focus on those related to drug company payments?

Yes, many forces and experiences influence our opinions. As a psychiatrist, for example, I might choose drug X over drug Y because:

--A relative did well on drug X.
--A relative did poorly on drug Y.
--I don’t like company Y’s marketing practices.
--I publish a newsletter, and my readers enjoy hearing me criticize drug Y.
--I’ve made $1 million doing promotional talks for drug X, and I’d like to make another million (I haven’t!).
--I’ve done 10 years of research on drug X’s mechanism of action, and if I get one more paper into New England Journal of Medicine I’ll be promoted to full professor.

And so on. There are innumerable sources of potential bias, and we should disclose those that are most clearly identifiable. In my opinion, financial conflicts are the easiest to identify, and also the easiest to resolve. I can choose not to take the money, but I cannot choose to change the fact that a relative did poorly on drug Y, or that I have staked my career on drug X, etc….

This is why we focus on financial conflicts of interest.

4. Finally, this is not about whether Senator Grassley, Senator Kohl, or the New York Times are trying to destroy psychiatry as a profession.

Most of the targets of Grassley’s investigation have been psychiatrists. Some have been cardiologists, and some have been orthopedists.

Psychiatrists have been particularly targeted because, at least in two of the states where drug companies are compelled to disclose payments to physicians, psychiatrists have topped the list. As a profession, I believe psychiatrists are the most vulnerable to the blandishments of the pharmaceutical industry, for various reasons.

First, we psychiatrists make less money than most other medical specialties, and want to supplement our income with drug company money. Second, psychiatrists, by abandoning psychotherapy to those “lower” on the pecking order, such as social workers and psychologists, have painted ourselves into a corner in which all we do is prescribe drugs. Thus, we are exquisitely dependent on information on pharmaceuticals, information which is usually funded by drug companies. Finally, we have a chip on our shoulders in relation to the rest of medicine. Are we “real” doctors? Are we as “good” or as “scientific” as our colleagues in other specialties? Psychiatrists obsess about such questions. Working closely with the pharmaceutical industry makes us feel valued, scientific, and powerful.

Let’s keep the focus where it belongs.

Open Letter to Dr. Frederick Goodwin

Dear Dr. Goodwin,

Thank you for taking the time to respond to my blog postings regarding this unfortunate disclosure controversy.

I’ll start by apologizing for the single false statement I made: “the segment itself was partially funded by Pfizer, maker of Zoloft.” I got that wrong. Pfizer did not fund that particular segment, but it has, indeed, been one of the underwriters of The Infinite Mind. According to the producer's website, many other drug companies have funded the program, including Eli Lilly, Abbott Laboratories, Scios, Searle, Janssen, and Solvay. According to an email from Bill Lichtenstein, the last drug company grant the show received was in 2005.

However, I stand by all my other statements. Regardless of who actually invited the guests, chose the topic, or suggested questions, you were ultimately responsible for what was said. You were there behind the microphone, asking questions, making comments, and steering the discussion.

While you appear to blame Mr. Lichtenstein for the show’s failings, saying that he put it together “in a hurry,” in fact Mr. Lichtenstein tells me that he did not produce this segment at all, and had hired a freelance producer to coordinate it.

You also blame Mr. Lichtenstein for the fact that Peter Pitt’s PR work for drug companies was not disclosed. However, you are on the board of directors of Center for Medicine in the Public Interest (CMPI), a pro-industry front group which receives a majority of its income from drug companies. Peter Pitts happens to be the president and co-founder of this same organization. How could you have not known of his financial relationships with the pharmaceutical industry? And assuming you did know, how could you have not made certain that this was disclosed to listeners?

You state that I am “damaging the reputation of distinguished academic scholars such as a professor at UCLA.” I assume you are referring to Andrew Leuchter, a professor of psychiatry at UCLA who was one of the guests on the Prozac Nation: Revisited show. In fact, I said nothing to damage his reputation. Dr. Leuchter is a brilliant researcher who I once interviewed for an article on the uses of EEG in psychiatric practice. He takes money from pharmaceutical companies for research on antidepressants, which he discloses on his website. There’s nothing wrong with that. But this information should have been disclosed to listeners—not to discredit him, but to alert listeners that these financial relationships might (or might not) have influenced his opinions about the dangers of antidepressants.

To conclude, I’m hoping that you and your supporters, such as John McManamy , will stop blaming everybody else for this mess. Don’t blame the New York Times—they were merely reporting the facts. Don’t blame scientologists—they haven’t even participated in this discussion. Don’t blame Bill Lichtenstein, Gardiner Harris, Charles Grassley, Slate Magazine, Shannon Brownlee, Jeanne Lenzer, or even Daniel Carlat.

This entire fiasco could have been averted if you had chosen to inform NPR listeners of your financial conflicts of interests at the beginning of shows focusing on pharmaceuticals.

Daniel Carlat, M.D.

Dr. Frederick Goodwin Responds to Carlat

Frederick Goodwin, who has been under fire from various quarters for apparently failing to disclose pharmaceutical company income to the producer of The Infinite Mind, has responded to my postings about this issue in the comments section of this blog entry. I thought it was an important enough response to feature it as its own post. I print it below in its entirety, and I will respond to his concerns in a separate entry.

I was very saddened and disappointed to read Dr. Carlat’s post. While he and I may disagree on certain issues, I had always assumed that he adhered to minimum scholarly standards in his writings, standards that are expected of professionals with academic backgrounds.

While I was taken aback by the polemical over-the-top language from a colleague with whom I worked in a recent American Psychiatric Association symposium, e.g. “outrageous betrayal of the listeners trust,” I was most profoundly dismayed by statements that were simply not true. (And can easily be shown to be false.) For example, he said that “Goodwin brought together experts with clear financial interest in arguing for the drugs’ [SSRI’s] safety.” First, he ignored what I said in the statement that I had sent him before he posted this blog, namely, that the producer of the Infinite Mind, not the host, reserved for himself full responsibility for the selection of topics, selection of guests, preparation of the script, and even the questions to be asked.

If Dr. Carlat did not believe me, but still wanted to protect his own credibility, he easily could have checked this out with Mr. Lichtenstein, the show's producer, or I would have been happy to send him a copy of the contract which specifies the producer’s total control of content. The fact that he went ahead with his own version of reality, in the face of assertions to the contrary in his possession, (assertions which he apparently did not check out) is reminiscent of what the Times’ Gardiner Harris did in simply ignoring any reality that didn't fit his narrative.

(Incidentally the particular show that Dr. Carlat was discussing was put together in a hurry by Mr. Lichtenstein working alone because he wanted to get something on the air to reassure stations that he could still produce a new show now and then. I didn't even know who the guests were until I arrived at the studio and got the script that had been faxed directly to the radio station. Mr. Lichtenstein later acknowledged that he had not determined in advance that one of the guests was affiliated with a center getting funds from a pharmaceutical company. While this was not disclosed, as it should have been, it was an oversight by a vastly overworked producer. But that's a minor point.)

More damaging to Dr. Carlat's credibility is his loose throwing around of reckless charges referring to “experts with clear financial interests in arguing for the drugs’ [SSRI’s] safety.” Incidentally by referring to Zoloft in this context he seemed not to be aware that this drug has been available in a generic form for some time now. One would like to assume that the author of a pharmacology newsletter would be aware that once drugs become generic there is no further “promotion” by pharmaceutical companies and therefore no “clear financial interests” of anyone. His sweeping statement is more than naïve - it's recklessly damaging the reputation of distinguished academic scholars such as a professor at UCLA. Many of the readers of his blog may not understand how naïve it is to talk about “promotion” of a drug that's been off patent. Dr. Carlat must assume responsibility not only for misleading his readers, but also for recklessly and falsely damaging reputations. To use his phrase, “that's bad journalism.”

But he gets even more reckless. He asserts as fact that “ the segment itself was partially funded by Pfizer, the maker of Zoloft.” Where did he get this information? From a Scientology website? Unless Dr. Carlat can document this, he owes me, the Infinite Mind producer, the guests, and, especially his readers, an apology.

Dr. Carlat’s blog is, to use his own words, a “particularly outrageous betrayal of the [readers] trust,” readers who have a right to assume that his statements reflect the standards associated with professionals in academia.

Frederick K. Goodwin M. D.

More Frederick Goodwin Developments

There have been a few developments regarding The Infinite Mind scandal since yesterday. Pharmalot posted a statement from Dr. Goodwin rebutting the New York Times piece. This statement had originally been published on an APA listserv, and was apparently leaked to Pharmalot--though not by me. I wrote directly to Dr. Goodwin to ask him if this statement was actually his, and whether I could post it, and he wrote back saying that he would send me a shorter version of the statement, which I'll post when I receive it.

Meanwhile, NPR's show On the Media aired this interesting 8 minute segment on the issue, which is worth a listen, because it brings these issues into perspective. Specifically, the host David Folkenflik points out that NPR is by definition a source of unbiased news, being the only major radio network which does not accept advertising. Thus, for it to air a show hosted by a psychiatrist who did not disclose $1.3 million in industry payments was a particularly outrageous betrayal of the listeners' trust.

Finally, you must check out this elegant essay by Jonathan Leo, which deconstructs, quote by quote, the notorious "Prozac Nation Revisited" show, during which Goodwin interviewed guests who shared his belief that the antidepressant-suicide connection is overblown. As it turns out, I mostly agree with Goodwin on this issue, but that's irrelevant. Whether antidepressants cause suicidality is a controversial point, with very complicated data on both sides of the argument. Goodwin brought together experts with clear financial interests in arguing for the drugs' safety (Nada Stotland is an exception, since she was there representing the APA and has no current pharma ties). Furthermore, the segment itself was partially funded by Pfizer, maker of Zoloft. The point is that the public was offered only one side of the debate, without having been informed of the fact. That's bad journalism.

Goodwin has been arguing that his pharma ties were available to anybody who chose to Google him, but this doesn't meet basic journalistic standards. Listeners should be able to trust NPR, and should not feel the need to rush to the internet to check up on every expert featured. That's why we suffer through those pledge drives!