Pharma, Outpatient Commitment High on APA Ethics Agenda

Another area of ethics that has grabbed the public's attention in recent years has been the issue of physicians' relationship with the pharmaceutical industry. APA has attempted to address the public's concerns about this relationship as it begins work on DSM-V by instituting an in-depth industry-relations disclosure, divestiture, and confirmation process for psychiatrists being considered for appointment to work on DSM-V, according to Donna Norris, M.D., secretary-treasurer of APA. The inherent intrusiveness of the process has drawn complaints from some, and several psychiatrists have refused to contribute to the DSM-V process because of it; however, many others have successfully completed the requirements of the disclosure process.

The issue of industry affiliations also applies to individual psychiatrists, said Carolyn Robinowitz, M.D., APA president.

“We are living in an age where we do have to question whether pharma is our friend or our foe,” Robinowitz said.

The greater importance and effectiveness of pharmacotherapy in recent decades, coupled with the role of industry as the primary funding source of psychiatric medication research, have created strong bonds between industry and medicine. Third-party payers also have encouraged the greater use of medications stemming from a single visit, instead of talk therapy over many visits.

“And patients often prefer less time spent in a doctor's office and more of the magic that newspaper advertisements and movies tell us about medications,” she said.

Differentiations between education and marketing became entangled because drug companies traditionally undertake new drug development and disseminate much of the information about new medications and newer uses for older medications.

“They want people to use their product properly, but they also want people to use their products, and sometimes those are a bit in conflict,” Robinowitz said.

In response to a question from Robinowitz about who received what free drug samples from manufacturers, only one audience member said they had received generic as well as name-brand samples.

The questions surrounding industry promotion should not be allowed to overwhelm the advocacy role of psychiatrists, which entails informing the public that treatment works and is available and affordable. It is important to remember, she said, that the research shows that the best patient outcomes often stem from a combination of medication and talk therapies.

Increasing questions among policymakers and the media about the influence of the drug industry on clinicians' pharmaceutical prescribing patterns mean that psychiatrists need to be as circumspect and as open as possible. If the public is convinced that conflicts exist, then policymakers will enact overly simple “solutions,” or patients will lose trust in their clinician's treatment plan.

“We need to be clear about what we do so that the science doesn't get tainted. That's the bottom line,” Robinowitz said.

She called for specific steps to clarify the role of industry. One step would have psychiatry residents meet with an industry representative and a senior faculty member “who understands the literature and who can help them evaluate and assess what they are being told,” which will help them develop critical thinking and assess what they are told by drug makers.

Robinowitz urged individual psychiatrists to disclose industry relationships as fully as possible, while avoiding the use of company-provided items that feature drug names or manufacturer names. Any industry-funded presentation meals are marketing, she said. And presenters should always disclose any industry funding they have received.

Researchers also can avoid ethical conflict allegations by making sure they register, review, and report industry relationships. The Association of American Medical Colleges responded to growing concerns about researcher conflicts in recent months by issuing specific principals to maintain the integrity of clinical research.

“We need to educate people about these relationships and about critical evaluation and prohibit inappropriate participation,” Robinowitz said. ▪