Thomas Insel, Director of the National Institutes of Mental Health, gave a plenary address to the Neuroethics Society on Saturday entitled “Conflict of Interest in Psychiatry”. Using data provided by the PharmedOut, a Georgetown University Medical Center-based project that empowers physicians to identify and counter inappropriate pharmaceutical promotion practices, Dr. Insel walked through a series of observations that suggest that psychiatry is particularly heavily targeted, and influenced, by the pharmaceutical industry. Among the eye-popping observations that were shared were these:
Of 394 physicians who received over $100,000 from the pharmaceutical industry, 116 were psychiatrists, well out of proportion to the percentage of psychiatrists in medical practice.
Antipsychotics are the top-selling class of drugs in the United States, with sales of $14.6B. What is most remarkable about this observation is that the older antipsychotics, which are no longer protected by patents, are of equal or superior effectiveness to the current crop of second-generation antipsychotics, but physicians prescribe the new ones at a huge cost to society.
An important observation that I had never heard before was that disclosure of conflict of interest is not the same as lack of conflict of interest. Dr. Insel cited the work of George Loewenstein and his colleagues who report that,
Conflicts of interest can lead experts to give biased and corrupt advice. Although disclosure is often proposed as a potential solution to these problems, we show that it can have perverse effects. First, people generally do not discount advice from biased advisors as much as they should, even when advisors’ conflicts of interest are honestly disclosed. Second, disclosure can increase the bias in advice because it leads advisors to feel morally licensed and strategically encouraged to exaggerate their advice even further. This means that while disclosure may [insufficiently] warn an audience to discount an expert-opinion, disclosure might also lead the expert to alter the opinion offered and alter it in such a way as to overcompensate for any discounting that might occur. As a result, disclosure may fail to solve the problems created by conflicts of interest and it may sometimes even make matters worse.
While it was refreshing to have the director of NIMH speak to the challenges that conflict of interest pose, it was not lost on many audience members that this presentation seemed to be a bit of a mea culpa. More than one audience member remarked to me that Insel had been sullied by his minor role in l’affaire Nemeroff, where he made phone calls on behalf of his former Emory colleague Charles Nemeroff, a well-known psychiatrist who was negotiating for a new job after he lost his position at Emory over abusing conflict of interest rules.
Towards the end of his lecture, Insel suggested that we move from pointing fingers at culprits (be it the pharmaceutical industry or individual physicians) and begin to search for solutions. He even hinted, in response to a comment from the audience which insinuated that NIMH has been as much a part of the problem as the pharmaceutical industry and the psychiatric profession, that NIMH might fund studies whose objectives were to find solutions to the pervasive conflict of interest problem in psychiatry. Sharpen you grant-writing pencils.
Link to PharmedOut
Link to The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest
Link to article on lnsel and l’affaire Nemeroff