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.