NIMH Director on Industry Influence over Psychiatry

The current JAMA (subscription required) features a commentary by Dr. Thomas R. Insel, Director of the National Institutes of Mental Health, on the problem of Pharma influence over psychiatry. Our blogging friends have quite different takes on the matter.

To Barney Carroll--
http://hcrenewal.blogspot.com/2010/03/dr-pangloss-as-nih-institute-director.html
--Dr. Insel has participated in a whitewash, spending most of the commentary making excuses that psychiatrists are at the pharmaceutical industry trough about the same amount as the pigs from other medical specialties, so it is unfair to single them out. Dr. Carroll opines that this whitewash may be motivated by Dr. Insel's close ties with Dr. Charles Nemeroff, whose escapades we have detailed on numerous occasions and is basically the poster child for academic psychiatrists eagerly doing the bidding of industry. Dr. Insel alludes elliptically to "the resignation of a chair of a prestigious psychiatry department" as one of the "major effects" produced by heightened publicity around conflicts of interest in his field. (Nemeroff, as we have covered, resigned as chair at Emory but soon after was hired on as chair by Miami.)

To Danny Carlat--
http://carlatpsychiatry.blogspot.com/2010/03/dr-tom-insel-nimh-chief-scolds.html
--it is much more significant that Dr. Insel has severely scolded his fellow psychiatrists in a national medical forum. Just to add a bit of fuel to the debate, the first comment on Dr. Carlat's blog posting is from Dr. Insel himself, who disputes many of Dr. Carroll's facts regarding the close ties Insel allegedly had with Dr. Nemeroff.

So I read the Commentary in JAMA carefully to try to figure out whom I agreed with, and find myself in this instance backing Dr. Carlat's general take on the matter. I can see how Drs. Carroll and Carlat came to such different conclusions because the Commentary is strangely composed, and actually seems to be two commentaries published side by side. One, as Dr. Carroll states, is largely a defense of psychiatry against charges that its practitioners are of lower moral caliber than other specialists. The second, as Dr. Carlat correctly points out, is an attack on his specialty for allowing industry money to distract it from science and quality patient care. Dr. Insel focuses mostly on the many non-drug treatments for mental illness, which have been scientifically proven, and yet remain largely underused and in some cases unreimbursed due to psychiatry's love affair with medications.

Perhaps Dr. Insel made a calculation that he needed to include his first commentary, making excuses for psychiatrists, as a sort of sugar coating on the bitterer pill of his second commentary. If so, he may have miscalculated as mostly he just confuses the reader as to what his main point is. I'll hope that the "real" Dr. Insel is the guy who wrote: "[A]cademic leaders and their professional societies will need to transform what has become a culture of influence. The greatest threat to an era of improved public health stemming from the productive and ethically sound relationship among academia, industry, and practice is a defiant embrace of the status quo..."

Insel TR. Psychiatrists' relationships with pharmaceutical companies: part of the problem or part of the solution? [commentary] JAMA 303:1192-93, Mar. 24/31, 2010.

Psychiatry: Looking in the Mirror?

A recent editorial in the American Journal of Psychiatry--

http://www.beforeyoutakethatpill.com/2009/3/ajpconflictcommentary.pdf

--is notable for a number of features. First, it is signed by every editor of the journal and also by every member of the editorial board. That is very unusual for editorials in medical journals. So obviously it is supposed to indicate a serious discussion that has the buy-in of all involved parties.

Next, the editorial frankly admits the problem (thoroughly documented here in too many posts to summarize) of conflicts of interest among academic psychiatrists and the resultant loss of trust in the specialty as well as medicine more generally. Here and there a minor quibble or excuse is inserted, but the overall tone of the editorial is, folks, we have a real problem here, no more pretending that it's all OK.

Finally, the editorial presents the bald and unwelcome solution--if we are going to free ourselves from the tentacles of industry entanglements, we have to stop expecting the industry to foot the bill for our various dalliances. No more having our professional societies and all our CME paid for by the drug companies. We need to step up and to be willing to pay for a heftier chunk of our own professional obligations.

In all these ways the editorial seems to be a serious statement of the need for reform in one medical specialty that has been especially subjected to unwelcome publicity. For a more cynical take see that of my fellow blogger and academic psychiatrist, Dr. James Bremner:
http://www.beforeyoutakethatpill.com/index.php/2009/03/11/somewhat-lame-editorial-on-conflicts-from-american-journal-of-psychiatry/

As he responds as a psychiatry insider, it's hard to disagree with what he says. Form your own opinion.

Freedman R, Lewis DA, Michels R, et al. Conflict of interest: an issue for every psychiatrist. American Journal of Psychiatry 166:274-277, 2009.