Opinion: Bias Is Unavoidable

It is part of the human condition to have implicit biases—and remain blissfully ignorant of them. Academic researchers, scientists, and clinicians are no exception; they are as marvelously flawed as everyone else. But it is not the cognitive bias that’s the problem. Rather, the denial that there is a problem is where the issues arise. Indeed, our capacity for self-deception was beautifully captured in the title of a recent book addressing researchers’ self-justificatory strategies, Mistakes Were Made (But Not by Me)

Undue influence of drug firms may find way into diagnoses

Undue industry influence may be compromising the very guidelines that doctors rely on for diagnosing and treating patients. This is because of a legal, but controversial, practice that permits researchers with financial ties to pharmaceutical companies (such as those who participate on company speakers bureaus or who receive large research grants) to serve as experts on medical guideline-writing panels

Diagnosing Conflict-of-Interest Disorder

In June 2010, the Association of American Medical Colleges issued the third and final portion of its conflict-of-interest policy initiatives. The task force on “Conflicts of Interest in Clinical Care” did not mince words when it described the impetus for these initiatives: “It is imperative that the possibility or perception of [financial conflict of interest] be advertently examined and appropriately evaluated to ensure that academic medicine in all of its missions is fundamentally dedicated to the welfare of patients and the improvement of public health.” This report is especially timely because of recent questions raised by investigative journalists and policy makers about the extent of industry influence on the diagnostic guidelines of the American Psychiatric Association (APA). Much is at stake: the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is often referred to as the bible of psychiatric disorders because of its enormous influence on clinical practice, affecting such disparate domains as jurisprudence and insurance claims. The APA also produces and disseminates clinical-practice guidelines directly tied to DSM diagnoses. Thus, publication of the DSM-V, scheduled for 2013, will not only generate millions in additional revenue to the APA but also affect what health practitioners prescribe to patients. The people responsible for determining whether a new diagnosis should be added to the DSM, or whether the DSM’s descriptions of symptoms for current disorders need revision, should not benefit financially from their recommendations. For example, if a DSM panel member is a major stockholder in a pharmaceutical company that manufactures a drug used to treat a disorder, a clear conflict of interest exists

Psychiatric Taxonomy, Psychopharmacology and Big Pharma

Clinicians practicing today need to be aware of the ways in which the current industry-dominated climate may undermine the integrity of the scientific process and, thus, may compromise patient care. In the mental health field, corporate sponsorship bias can affect psychiatric taxonomy and clinical Practice Guidelines (CPG). Financial conflicts of interest (FCOI) can occur when there are financial associations between researchers, authors, or panel members developing psychiatric diagnostic and treatment guidelines, and the pharmaceutical industry, or when randomized clinical trials (RCTs) are industry funded. Therefore, clinicians need to be especially vigilant about the informed consent process when patients are prescribed psychotropic medications

Finding Solutions to Institutional Corruption: Lessons from Cognitive Dissonance Theory

The American Psychiatric Association and academic psychiatry in the United States have two conflicts of interest that may affect their assessment of psychiatric drugs and their development of diagnostic and clinical care guidelines: payments from pharmaceutical companies and guild interests. Until recently, the proposed solution to industry-academic relationships has been transparency. However, cognitive dissonance research reveals that disclosure is not a solution because cognitive biases are commonplace and difficult to eradicate. Indeed, bias is most often manifest in subtle ways unbeknownst to the researcher or clinician, and thus is usually implicit and unintentional. Also, recent studies suggest that disclosure of financial conflicts of interest may actually worsen bias. In this paper we discuss the implications of cognitive dissonance theory for understanding why disclosure or even management of financial conflicts of interest are not robust enough solutions to guarantee objectivity and prevent bias. We suggest that as a gold standard commercial ties should be eliminated in settings where new drugs are being tested and assessed, or clinical guidelines are being developed. This solution will require the use of multidisciplinary teams to do the tasks, including methodologists in addition to psychiatrists

Conflicts of Interest in Clinical Practice Guidelines

Clinical practice guidelines are used increasingly across medical specialties and settings, making evaluation of their utility and validity a critical public health issue. In this paper, we describe some of the challenges that specialty organizations face as they try to ensure that their guidelines are trustworthy and useful. We examine the practice guidelines for Major Depressive Disorder recently published by the American Psychiatric Association (APA), identify five sources of potential bias that may affect the guideline development process and offer suggestions based on our review. For example, even for mild depression, this guideline privileges pharmacotherapy over other interventions, despite questions about the risk/benefit ratio and the increasing concern over the iatrogenic harms of SSRIs and SNRIs. We compare recommendations from international scientific groups (e.g. NICE) with those produced by specialty societies in an effort to demonstrate some of the ways in which conflicts of interest, both intellectual and financial, may unduly influence guidelines

Pharmaceutical Philanthropic Shell Games

In response to increasing public distrust and congressional concerns regarding pharmaceutical company influence on medical research and education, professional organizations have taken steps to phase out or regulate industry-sponsored educational support. A related problem is industry funding of philanthropic organizations, such as patient advocacy groups. Thus, when the office of Sen Charles Grassley (R-Iowa) recently reported that the National Alliance for the Mentally Ill received substantial pharmaceutical funding, there was concern among the membership’s psychiatric patients and their families

Undue Pharmaceutical Influence on Psychiatric Practice

Within the past few years, increasing concerns have arisen about the ways in which corporate sponsorship of clinical trials and continuing medical education activities may bias the information that is published and disseminated about the benefits and risks of medications. Questions have also been raised about the extent of industry influence on the American Psychiatric Association’s diagnostic and treatment guidelines—namely, its DSM and Clinical Practice Guidelines

Industry’s Colonization of Psychiatry: Ethical and Practical Implications of Financial Conflicts of Interest in the DSM-5

The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), scheduled for publication in May 2013 by the American Psychiatric Association (APA), has created a firestorm of controversy because of questions about undue industry influence. Specifically, concerns have been raised about financial conflicts of interest between DSM-5 panel members and the pharmaceutical industry. The authors argue that current approaches to the management of these relationships, particularly transparency of them, are insufficient solutions to the problem of industry’s capture of organized psychiatry. The conceptual framework of institutional corruption is used to understand psychiatry’s dependence on the pharmaceutical industry and to identify the epistemic assumptions that ground the DSM’s biopsychiatric discourse. APA’s rationale for including Premenstrual Dysphoric Disorder (PMDD) in the DSM-5 as a Mood Disorder is reviewed and discussed

Toward Credible Conflict of Interest Policies in Clinical Psychiatry

A recent letter to the American Psychiatric Association (APA) from Sen Chuck Grassley about the APA’s financial relationship with pharmaceutical companies raises concerns about undue industry influence. By instituting a disclosure policy for DSM-V, the APA took a halting first step in restoring public trust in the most influential text on psychiatric taxonomy in the world. Unfortunately, the APA’s efforts at creating a conflict of interest (COI) policy have failed to ensure that the process for revising diagnostic and therapeutic guidelines is one that the public can trust. The need for more safeguards was evidenced when the APA reported that of the 27 task force members of DSM-V, only 8 reported no industry relationships.2 The fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed