Psychiatry and the pharmaceutical industry: who pays the piper?

There is increasing concern about the relationship between medicine and the pharmaceutical industry. In July the BMJ devoted a themed issue to this, and critical discussions have featured in other leading medical journals recently. The industry has grown in profitability and influence over the past 20 years, and is now second only to armaments in the US economy (Public Citizen, 2002). Its influence is enhanced through its control of research, and it employs sophisticated and wide-reaching marketing strategies. This level of influence is concerning because the private investment necessary to enable drug development demands ever more vigorous struggles to maintain and expand market presence. In other words, commercial rather than clinical or scientific demands are becoming the dominant driving force for ‘innovation’. This leads to the popularity of developing cheaper ‘me too’ options, and the promotion of new ‘disease concepts’ to allow the re-badging of old products to expand markets without major development costs.

Influence of the pharmaceutical industry

We believe that psychiatry is particularly vulnerable to the influence of the pharmaceutical industry for a number of reasons:

1. (a) There is no objective test for external validation of psychiatric disorders. This means the boundaries of ‘normality’and disorder are easily manipulated to expand markets for drugs. For example, the Defeat Depression campaign, in part (<30%) supported by the pharmaceutical industry, advocated increased recognition and treatment of depression in general practice. This coincided with a sharp rise in prescriptions for antidepressants. The value of the widespread drug treatment of unhappiness in primary care is now being questioned (National Institute for Clinical Excellence, 2003). In the USA drug companies have conducted campaigns to promote the idea that conditions including social anxiety disorder, post-traumatic stress disorder and premenstrual dysphoric disorder are common psychiatric disorders requiring drug treatment. This practice has been criticised for medicalising social and personal problems (Moynihan et al, 2002).

2. (b) Psychiatric research is particularly susceptible to the influence of vested interests, including (but not restricted to) those of the pharmaceutical industry. This is because of the subjective nature of diagnosis and outcome, the variable course of most psychiatric disorders and the importance of placebo effects, including the context of participating in a research project. Empirical research has shown how the design, conduct and reporting of psychiatric research sponsored by industry can be shaped to convey a favourable profile of the sponsor's drug (Safer, 2002; Melander et al, 2003).

3. (c) The psychiatric profession has been inclined to favour biological models of mental disorder and physical treatments as a means of bolstering its credibility and claims to authority in the management of mental disorder (Moncrieff & Crawford, 2001).

Consequences

The influence exerted by the pharmaceutical industry affects patients, carers, society and psychiatrists. Patients may receive care that unduly emphasises drug treatments. The adverse effects of drugs are downplayed, and alternative approaches to distress neglected. Patients and carers are led to believe that there are simple, drug-based solutions to their problems, leading to disillusion and disappointment when this turns out not to be so. The medicalisation of social and personal problems diverts attention and resources away from social, political and spiritual understandings of distress and is testimony to the power of psychiatry to create subjectivities (Thomas & Bracken, 2004).

Psychiatrists risk losing both the reality and the semblance of independence. Torrey's description of the flamboyant advertising installations created for the World Congress of Biological Psychiatry in 2001, including a 12-m rotating tower constructed by Novartis and an artificial garden created by Janssen, confirms the importance of psychiatry in pharmaceutical marketing (Torrey, 2002). Research confirms that marketing practices do influence prescribing adversely (Wazana, 2000).

Perhaps more fundamentally, however, the nature and theory of psychiatry are being shaped by the interests of the industry. Drug company information conveys and helps to reinforce simple messages about mental disorders being caused by chemical imbalances (see, for example, the website http://www.prozac.com), and the ubiquity of the industry's message pushes psychiatry into a biological straitjacket. The proliferation of links between both individuals and institutions and the industry has been well documented (Boyd & Bero, 2000). At the individual level, links include consulting fees, research grants, educational sponsorship and all forms of hospitality. Professional organisations - including the Royal College of Psychiatrists - are subsidised through payment for advertising space at educational conferences, sponsorship of other educational events and advertising in journals. The industry is also increasingly sponsoring aspects of service provision within the National Health Service. The extent of entanglement makes it more and more difficult to articulate alternative visions of psychiatric care.

Remedial action

There are steps that psychiatrists must take to distance themselves from the industry, and to regain their independence. The College should be congratulated for addressing this issue, although its recently published guidelines (Katona & Cameron, 2003) are not powerful enough.

The profession needs to engage in a wide-ranging discussion about the ethics of drug company hospitality and gifts. The subsidy of continuing medical education, both locally and nationally, should be examined. The aim should be to minimise or eliminate the use of such subsidies, at least for local teaching, which at little cost to the sponsor is a key influence upon trainees. If sponsorship is deemed essential, the use of blind trusts should be investigated as an alternative to direct sponsorship. Declaration of interests must be strongly enforced, and the College should establish a Register of Members’ Interests, which would require all members to disclose annually the value of gifts and sponsorship received from drug companies. This information must be in the public domain, along the lines of the Register of Members’ Interests in Parliament.

From a public perspective, the profession should participate in initiatives to provide good-quality, impartial information about the pros and cons of drug treatments for patients and professionals. Although the National Institute for Clinical Excellence (NICE) guidelines were intended to provide comprehensive impartial reviews, NICE has been criticised for allowing the industry to exert an overly strong influence on the process of guideline development, with the result that some guidelines appear to reflect marketing interests (Healy, 2003).

Conclusions

In an era of reduced government expenditure on research, the pharmaceutical industry is funding and conducting an increasing proportion of research on medical drugs. It is also increasingly involved in funding some aspects of health services, part of the general pattern of private sector involvement in state services associated with globalisation (Price et al, 1999). This means the industry has an increasingly powerful role in determining how psychiatry is perceived and what psychiatric treatment consists of. The proliferating connections between psychiatry and the drug companies make it difficult for anyone to challenge this situation. Psychiatrists must take steps to ensure their independence for the sake of their patients, the public and their reputation.

Declaration of interest

None.