APA-Pharmaceutical Relations
Despite Dr. Paul Appelbaum’s editorial response in the January 17 issue to letter writers concerning members’ involvement in APA, I would like to chance a strong criticism of what I perceive as APA’s neglect of a matter I find most crucial to our profession, that is, our relationship with the pharmaceutical industry, which has already engendered some public distrust and at least one major legal action. That industry has been coming under increased—and well-deserved—criticism of its dominance of the means of research into new drugs and their marketing (see the article by Drs. Relman and Angell in the December 16, 2002, New Republic), its unscientific and self-serving clinical testing (see JAMA, January 22/29), and its methods of inducing psychiatrists into using them.
I find these criticisms serious enough, especially since we find ourselves intimately involved, but what troubles me more is the extent to which the industry is determining the education and training of psychiatrists (and associated professionals, as well as the public) so that medications and the presumed neurophysiological defects (“chemical imbalance”) they are designed to correct have assumed the primary—and at times only—focus of evaluating mental disorders.
I consider this situation to be one that should also concern APA, but I have seen no evidence that it has. It is hoped that Dr. Appelbaum and/or his successors will consider investigating it, especially if I promise not to cancel my subscription!
Dr. Appelbaum responds:
I—and I daresay the rest of APA’s leadership—share what I take to be Dr. Goldstein’s basic premise: the medical profession’s web of relationships with the pharmaceutical industry has created a complex set of ethical problems for us to manage. The evidence of APA’s concern can be found in the rules that govern the industry’s participation at our annual meeting, the intense and time-consuming monitoring of the industry-supported symposia, the attention given to these issues by APA’s Ethics Committee, and the endless discussions among APA leaders.
When all is said and done, however, there are two approaches to dealing with the efforts of the industry to influence our prescribing practices—an activity intrinsic to our capitalist system. We can, as some of our members have proposed, shun all contact with the pharmaceutical industry: accept no advertising in our journals, reject funding for newsletters and fellowship programs for residents, and exile industry-supported symposia from our annual meeting and industry booths from our exhibit floor. This approach has the virtue of absolute simplicity, but, I’m afraid, suffers from the simplicity of absolute virtue.
Alternatively, we can acknowledge that some industry activities are more problematic than others and respond accordingly. As I’ve noted in these pages before (Psychiatric News, August 16, 2002), in a society saturated with advertising, I find little objectionable about accepting pharmaceutical ads in our journals. Anyone who chooses not to read them can page right past. Similarly, anyone who doesn’t want to frequent the exhibits sponsored by the pharmaceutical companies can ignore them. To be honest, that’s what I do. In addition, it has always seemed to me that encouraging the industry to spend some small fraction of its profits supporting fellowship programs for residents, over which the companies have no influence at all, is a social good.
Other activities, however, have a greater potential for causing harm and need to be excluded entirely (for example, expensive gifts, including trips and phony honoraria, for physicians in a barely concealed effort to bribe them to prescribe a company’s medications) or monitored closely to ensure that commercial considerations don’t overwhelm educational ones (for example, the industry-supported symposia at the annual meeting). This is a more arduous path, but insofar as it encourages us to make more careful moral distinctions—and to hold onto that baby while tossing the bathwater—it makes more sense to me.
A final note. Dr. Goldstein’s allegation that “the [pharmaceutical] industry is determining the education and training of psychiatrists” is not correct. The requirements for psychiatric training are developed by the Residency Review Committee for our field. Many programs, my department’s included, have long emphasized training in psychotherapy alongside education about psychopharmacology, and the industry plays no role in the latter. Indeed, for the first time all psychiatry programs are required to include training in psychotherapy in their curricula and to document the attainment of competency in several forms of psychotherapy by their residents.
I appreciate Dr. Goldstein’s having taken the time to write, and I’m glad that he won’t be canceling that subscription. ▪
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Published online: 4 April 2003
Published in print: April 4, 2003
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