Psychiatry’s Harmful Conflicts of Interest

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When Congress passed the Physician Payments Sunshine Act in 2010, the new law was meant to “provide for transparency” in the relationship between healthcare providers and pharmaceutical manufacturers. It required drug makers to disclose direct payments to physicians and to help uncover conflicts of interest. At stake was a principle of self-correction in medicine free from the taint and bias of commercial interests.

A recent report on the latest seven years of data (2014-20) submitted to the Centers for Medicare and Medicaid Services (CMS) joins mounting evidence that the legislation has not been successful. Instead, the report concludes, “the most remarkable result of the Open Payments legislation is that the pharmaceutical companies are no longer attempting to hide this financial influence.”

In Anatomy of an Industry, a 39-page report published earlier this week by Mad in America, lead author Robert Whitaker, co-author of the 2015 study Psychiatry Under the Influence, singles out the legislation as a false panacea. The legislation gives an illusion of transparency and accountability in fields where conflicts of interest (COIs) are, in fact, endemic, and drug studies are routinely conducted by company authors with direct financial incentives in the drug’s approval.

“If the payments became public, the thinking went, medical school faculty would shy away from serving as the named authors on ghostwritten papers reporting clinical trial results, and they would refrain from being paid to give promotional talks as companies built markets for their newly approved drugs,” according to the paper. Instead, in our era of disclosure, Whitaker finds, “the face of commerce is visible at every stage of the process: the biased design of the trials, the spinning of the results, and the subsequent touting of the drugs to prescribers.”

Between 2014 and 2020, the CMS database shows, pharmaceutical companies made a total of $340 million in direct payments to U.S. psychiatrists. The services included consulting, advising, and promotional speaking, and they are itemized to include “Travel and Lodging” and “Food and Beverages,” which themselves reach multi-million dollar payments.

The report also names 62 U.S. psychiatrists who “received direct payments from pharmaceutical companies totaling $1 million or more from 2014 through 2020.” The top-earner received $8.6M, of which $6.6M was from a single drug maker for helping to bring its antidepressant to market in 2013. A significant number of psychiatrists on the list are shown to have “no connection whatsoever to an academic medical school.”

Anatomy of an Industry also targets the close involvement of pharmaceutical companies in pivotal clinical trials by revisiting the approval of seven recent drugs. 23 of the 25 authors involved, “received payments from the drug companies that sponsored the trials, either during the trial or after FDA approval of the drugs.” In six other pivotal studies for schizophrenia and bipolar disorder, “18 of the 30 authors were employees of one of the three companies. Two of the 18 employees were also patent owners of the drug. Of the 12 non-employees named as authors, 11 disclosed financial ties to at least one of the companies.”

As Jon Jureidini and Leemon B. McHenry showed in their exhaustive 2020 study The Illusion of Evidence-Based Medicine, and as additional evidence has also brought to light, the problem of influence and cherry-picked outcomes extends through review and publication; it begins with the inclusion and exclusion criteria used to design clinical trials, often by excluding patients described as “treatment resistant.”

Via the same database and report, the official journal of the American Society of Clinical Psychopharmacology is shown to have published “at least 53 reports about the seven new drugs,” during which time its board members were also “paid $8 million by pharmaceutical companies, with most of the funding coming from the makers of the new drugs.” A second, industry-friendly journal published more than 71 articles about the seven new drugs, its lead authors receiving “$12.9 million by pharmaceutical companies from 2014 to 2020.”

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“For the public to trust the science,” the Anatomy of an Industry report concludes, “it needs to believe that it is free from commercial influence. The trials should be conducted by independent investigators, and subsequent reviews of the drug and conference talks should be free of industry taint as well.”

But as the report also shows in detail, the $340 million made in direct payments to U.S. psychiatrists encapsulates an open secret about the financial entanglement: it is widespread, systemic, and seemingly unstoppable, because it is now taking place right out in the open.