I’ve come across an article by Lisa Cosgrove et al entitled Conflicts of interest and the quality of recommendations in clinical guidelines. It was published in the Journal of Evaluation in Clinical Practice in December of last year.
As everyone knows, the APA publishes the DSM, but they also publish “Clinical Practice Guidelines” for various “diagnoses,” including the condition known as major depression.
Dr. Cosgrove and her colleagues examined the guidelines for major depression to see if the authors had financial or intellectual conflicts of interest. An example of a financial conflict of interest would be recommending drug treatment when one is on the payroll of a drug company. An example of an intellectual conflict of interest would be relying on and citing a poor quality study in support of a position in which one had a stake.
Here’s their summary of their findings:
“Fewer than half (44.4%) of the studies supporting the recommendations met criteria for high quality. Over one-third (34.2%) of the cited research did not study outpatients with major depressive disorder, and 17.2% did not measure clinically relevant results. One-fifth (19.7%) of the reference were not congruent with the recommendations. Financial ties to industry were disclosed by all members (100%) of the guideline development committee with members reporting a mean 20.5 relationships (range 9–33). The majority of the committee participated on pharmaceutical companies’ speakers’ bureaus. Members of the independent panel that reviewed the guidelines for bias had undeclared financial relationships. As a marker of intellectual conflict of interest, 9.1% of all cited research and 13% of references supporting the recommendations were co-authored by the six guideline developers.”
In my view there are three possible interpretations of these findings.
1. APA simply doesn’t get it. Maybe they just don’t understand that large sums of money distort people’s judgment. Or maybe they think that psychiatrists are so pure and uncorruptable that financial conflicts are irrelevant.
2. Maybe all psychiatrists of eminence (and I use the term loosely) are in the pay of pharmaceutical companies. So the APA literally can’t find unaligned panel members.
3. Maybe the APA just doesn’t care.
I can’t even begin to guess which of these might be accurate.
From time to time we read in the news that the Air Force is preparing to order a new bomber or fighter or whatever. So they form a committee of generals and other high ranking people to study options and make recommendations and decisions. Imagine if it were disclosed that all the officers on such a panel had received large sums of money from Lockheed Martin, say, but nothing from Boeing. Then imagine that all these individuals said that the money had in no way influenced their decision; that they had reviewed the competitors’ products professionally and impartially, and the Lockheed Martin plane was simply better. Half the country would probably die from laughing.
But isn’t this what the psychiatrists have done?
Dr. Alan J. Gelenberg, chair of the APA guidelines panel, reported the following positional conflicts for the period May 2005 to May 2010:
“Dr. Gelenberg reports consulting for Eli Lilly and Company, Pfizer, Best Practice, AstraZeneca, Wyeth, Cyberonics, Novartis, Forest Pharmaceuticals, Inc., GlaxoSmithKline, ZARS Pharma, Jazz Pharmaceuticals, Lundbeck, Takeda Pharmaceuticals North America, Inc., eResearch Technology, Dey Pharma, PGxHealth, and Myriad Genetics. He reports serving on speakers bureaus for Pfizer, GlaxoSmithKline, and Wyeth. He reports receiving research grant funding from Eli Lilly and Company, Pfizer, and GlaxoSmithKline. He reports stock ownership in Healthcare Technology Systems.”
The disclosure doesn’t reveal a total dollar amount, but Dollars for Docs (ProPublica) shows that he received $110,863 in research grants in 2011-2012 from Pfizer alone!