‘Big Pharma’ and Psychiatry: ‘The devil is in the dyad’

The recent debate in ANZJP has rightly spoken to the power of big pharma’s role with respect to psychiatry. It also begs the question of whether psychiatry is basically in a ‘dyadic’ relationship with it: i.e. a sociologically significant relationship, essentially regarded as a pair (The American Heritage Dictionary, 2000). That is how some outside of psychiatry currently perceive it (New York Times, 2008), regardless of ‘declarations of interest’. If this is the case, then our profession could be viewed as an ‘appendage’ of big pharma.

In the United States, big pharma already arguably dominates public consciousness with respect to understanding of psychiatric disorders and resulting perceptions of psychiatry. In part, this can be attributed to the impact of aggressive direct-to-consumer television advertising. Under the guise of public education, it has made some disorders appear far more common than they actually are. In so doing, it has successfully promoted some psychotropics far beyond their importance (Angell, 2004). Its interactions with physicians have been similarly pernicious: be they dinners, gifts, samples, funding of travel and lodging for symposia, and even CME sponsorship (Wazana, 2000).

To assume that physicians have been immune from such chronic and pervasive influences would be naïve. For example, it has been reported that the majority of DSM 5’s Task Force members have financial ties to big pharma (Cosgrove and Krimsky, 2012). Though it refutes the actual percentage, the American Psychiatric Association (APA) acknowledges that 28% of Task Force members have had such links, in the form of grant support of clinical trial research (12%), consultations for development of new compounds to improve treatments (10%), and honoraria (7%) (Oldham, 2012). It has tried to assuage these concerns by setting limits on honoraria to $10,000 (USD) of a Task Force member’s annual salary. It also goes on to laud individuals who, of their own accord, have relinquished such interests altogether.

However, this speaks directly to the core ethical dilemma as to who should be taking the lead on this issue. Perhaps in this case, APA inadvertently absolved itself of the valuable opportunity to apply the ‘top down’ or deontological ethical stance (Dyer, 1999) - by not explicitly stipulating tenets for what the relationship with pharma should really entail, including the holy grail of whether any financial relationship between big pharma and psychiatry can ever really be ethically justified as in the greater public interest (speaking to the ethical principal of utilitarianism). Instead, it appears to have limited itself to the teleological (Dyer, 1999) or ‘bottom up’ stance of leaving it to individual members of the Task Force to relinquish such ties. Thus, the arbitrary $10,000 limit appears to avoid the uncomfortable question altogether. In turn, this keeps the boundaries, the relationship and each party’s motives as blurry as ever.

Key opinion leaders (KOL’s) could be pivotal to such discussions because, as leaders, their conscious stewardship of this issue will determine perceptions of impropriety, whether they are ‘unconsciously’ motivated or not. Like Supreme Court Justices, leaders in psychiatry must be seen to be impartial and incorruptible. Unfortunately, examples of KOL’s income streams (Carlat, 2010) have cast doubt on whether the values espoused by the profession’s leadership are actually embodied, or whether they seem diluted by platitudes that will eventually wear thin. How else can our profession effectively answer criticisms that academic psychiatry has become the ‘mouthpiece’ for big pharma, or that it is being influenced by incentives?

A fundamental overhaul of the entire publication approval process itself may also be required. Footnoted acknowledgments and disclaimers at the end of papers currently appear too perfunctory an answer to such concerns. Recent responses to the controversial Lancet article (Hickey and Rogers, 2011) thus gave voice to the collective and intuitive uneasiness at how academic inferences are made in such a context. In disagreement with some (Ryan, 2012) I think it was entirely appropriate to raise such concerns within the pages of a peer-reviewed journal. It is right that we raise this issue first and openly within our ranks, well before outside agencies or the public do so.

This debate has therefore ‘pulled back the curtain’ on ‘inner’ motivations and their relation to ‘outward’ behaviors. The issue of conscious and unconscious motives as well as biases has already been raised (Smith, 2012). Building on psychodynamic and ethical precepts, a re-examination of our profession’s ‘observing ego’ and its ethical values might be necessary: in order to examine psychiatry’s ‘true gain’ from such a relationship, to stem the sole blame onto pharma, and finally to examine that which psychiatrists would have to forego, without pharma. This would include not only the obvious tangibles such as honoraria and funding, but also narcisstically-motivated intangibles such as peer recognition and career advancement (Smith, 2012).

Earnest ‘soul searching’ will also be needed to comprehensively address the issue of who (or which institutions) should really be funding psychiatric research. To this end, there have been no suggestions of scaling back the percentage of research funded by big pharma, or whether we as a profession should insist that big pharma funds research in which it would have no direct stake - as a public service initiative, and not merely to advance its shareholders’ interests.

As psychiatrists, we are widely regarded as relationship experts - often asked for ‘the truth’ when things go badly wrong. Yet, with respect to defining the contours of our own profession, we ourselves seem to have gone so badly wrong. It is natural to want to re-examine what is and what is not permissible when that occurs. But, without the above context, such a micro-focus (replete with ever changing ‘rules’, caveats and disclaimers) may paradoxically end up obscuring the very truths that are intrinsic to such relationships (Moynihan, 2003). In all probability then, the devil was never ‘in the details’…it was always within the dyad.