Revealed: Pharma finances 60% of experts deciding which mental disorders qualify for insurance
A Bible with less than divine authorship
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) and is commonly referred to as the “bible” of psychiatric disorders, as its listing of “mental illnesses,” along with descriptions of their various symptoms, is considered definitive. Therefore, not only psychiatrists consult it, but also insurance companies when deciding if and how much to reimburse clients for treatment.
Given the obvious interest pharmaceutical companies have in increasing the number of prescriptions for their products, it is crucial that those crafting the DSM be free of all Pharma bias. Unfortunately, this is not the case. A recent study conducted by Professor Lisa Cosgrove of the University of Massachusetts, published in the BMJ (British Medical Journal), confirmed widespread conflicts of interest among those behind the DSM, with over $14 million in Pharma money paid out to those with influence over its content.
Furthermore, despite the implementation of a disclosure policy for DMS-5 (the fifth and latest edition), the American Psychiatric Association did not publicly disclose its ties to industry in this edition, and it specifically excluded funds donated to research for DSM-5, which were the largest proportion by category of payment at over 70% of the total. (Other payments went mainly toward food and beverages, travel expenses, and consulting.)
Pharma payments made to almost 60 percent of DSM crafters
The study was made possible by the Physician Payments Sunshine Act, passed in 2013, which required all U.S. drug and device manufacturers to disclose payments made to physicians and teaching hospitals. A publicly accessible database, Open Payments, was subsequently set up to track such payments, and Prof. Cosgrove and colleagues used the information there to examine the crafters of the DSM (around 60% of whom are psychiatrists, 30% psychologists, and 10% other health professionals).
92 medical professionals were identified, and of those, 55 (59.8%) had financial ties to the pharmaceutical industry. These included people who served on the DSM task force (which historically has decision-making ability) as well as on the various panels, each of which debates a different “disorder.”
The rates of industry payments differed between the various diagnoses. On one panel, all of the members had received industry payments; on five other panels, over 75% of the members had received payments. Members of the panel examining medication-induced movement disorders received the largest amount of industry money—almost $8.5 million.
Overall, the areas in which industry made the largest payments are those where drug treatments are usually standard:
… we found that panel members of the Diagnostic and Statistical Manual of Mental Disorders who received the most remuneration from drug companies were those working in diagnostic areas where drug interventions are often the standard treatment, such as depressive disorders, neurocognitive disorders, and drug induced movement disorders...
Total compensation for each Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) panel and task force members during 2016-19
Money in, bad drugs out
The study’s authors stress the large amount of evidence correlating industry payments with pro-industry results, writing that,
... a wealth of research documents the ways in which academic-industry relationships lead to pro-industry conclusions, non-evidence based prescription practices, and untrustworthy guideline recommendations. [Emphasis added.]
The examples they cite illustrate the real-world implications of such practices being allowed to continue—unsafe medications approved for use as safe, as well as drugs portrayed as far more helpful and less harmful than they really are:
The impact of financial conflicts of interest on the medical literature, including randomized clinical trials, meta-analyses, and clinical diagnostic and practice guidelines, has been well documented for more than two decades. Indeed, researchers have consistently shown that conflicts of interest lead to subtle but impactful pro-industry thinking and conclusions.
For example, it was recently reported that when meta-analyses of antidepressants included an author who was an employee of the manufacturer of the assessed drug, the meta-analysis was 22 times “less likely to have negative statements about the drug than other meta-analyses.” [Emphases added.]
Similarly, when access to the full unpublished dataset was provided to researchers who conducted a reanalysis of SmithKline Beecham’s Study 329—an influential study concluding that paroxetine was safe and effective in adolescents—they found an increase in harms for paroxetine that was not reported in the published literature [emphases added].
They also stress that even subtle alterations to the DSM can have significant impacts, increasing substantially the number of people diagnosed with a specific disorder who thereby become eligible for insurance-funded medications:
Additionally, it is important to emphasize that the problem of overdiagnosis is not limited to the inclusion of new disorders in the Diagnostic and Statistical Manual of Mental Disorders. Even seemingly small changes to the manual (e.g. to symptomatology of previously included disorders) can have a substantial impact on increasing the number of people who would receive a diagnosis and increasing the number of people prescribed drugs.
For example ... the DSM-5 made the change that [ADHD] symptoms could appear before age 12 years rather than age 7 years; that symptoms need only to “impact” behavior rather than cause impairment… [emphases added].
‘You make us rich, we’ll make you great’
While some may claim that money donated to research is less likely to bias the researchers’ findings (an assumption that the authors of the study dispute), industry money donated in the form of “compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program,” effectively turns the recipients into “key opinion leaders” who gain credibility in the medical profession:
... key opinion leaders are influential not only because they are often affiliated with prestigious universities, but also because industry provides them with wide ranging and influential platforms and speaking engagements.
Prof. Cosgrove also noted that although some of those receiving industry payments were gifted less than $1,000,
… relatively minor gifts do affect physician behavior and prescribing practices; empirical research shows that even small gifts can have a substantial impact on behavior [emphasis added.]
Crisis behind closed doors
While Cosgrove and colleagues note that conflicts of interest also exist in other areas of medicine, they indicate that the problem may be most acute in psychiatry, citing one professional who said that
... “[T]he increasing influence of the pharmaceutical industry on psychiatric research and practice is leading to an intellectual and clinical crisis.”
Meanwhile, the American Psychiatric Association does not publicly disclose the minutes of the panel and task force meetings of the Diagnostic and Statistical Manual of Mental Disorders, making it impossible to know what exactly goes on behind the scenes.
It's human nature to be affected by bribes
Prof. Cosgrove and assistant Prof. Brian Piper (two of the study’s authors) discussed their study in a recent interview.
Prof. Cosgrove, who is a clinical psychologist, emphasized that conflicts of interest can arise without a person even being aware of it, because it is “part of the human condition to have biases and to remain blissfully unaware of them.” She added that,
… we often assume, quite wrongly, that the scientific process can protect us from those implicit biases …
She noted that the APA did not dispute her findings, but instead claimed that the conflicts of interest, “didn’t affect them, which is problematic, because it’s just part of the human condition to have implicit bias.”
Why should doctors be above suspicion?
Prof. Cosgrove also suggested that the medical profession is regarded as above suspicion by many, even people who naturally (and wisely) are distrustful of those conflicted by personal interest in other areas:
If you told people that eating a candy bar increased longevity and overall health and then they found out that that study was funded by Hershey, most people would be certainly skeptical ... And yet, sadly, when it comes to medicine, I don’t think people are as aware as they could be of the ways in which these conflicts can result in imbalanced and sometimes inaccurate information.
She also mentioned one very good reason why the public should be suspicious of the psychiatric profession in particular—the huge and increasing number of “sick” people:
... [consider] what’s called the prevalence paradox ... in areas of medicine other than mental health, when you have good treatments, then the prevalence of the disorders goes down. Antibiotics would be a paradigmatic example. Infectious diseases and bacterial infections went way down, a real game changer for humanity...
We don’t see that in the mental health field. We have more treatments, but we have an increasing number of people with disorders ... [and] there are actually no biomarkers for any of the DSM disorders ... [emphasis added]
Do what you can to protect yourself
Assistant Prof. Piper noted that the problems he and his colleagues discovered are not “limited to psychiatry. We’ve done other work looking at cardiology and oncology journals. This is a broad issue.”
And he provided one useful piece of advice to potential patients:
I would suggest: Before you go to your primary care provider, your psychiatrist, your physician assistant or your nurse practitioner, do a quick Google search for CMS Open Payments, and with a little bit of practice, ideally, if you know their middle initial, you can look up their conflicts of interest [emphases added.]
