In the world of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM) holds a significant role in shaping the understanding and treatment of mental health conditions. This paper delves into the intriguing history of DSM construction, focusing on the revelations made by Dr. James Davies, PhD, during his lecture titled “Psychiatry and Big Pharma Exposed.” Dr. Davies’ insights, along with the involvement of key figures such as Robert Spitzer and Dr. Alan Francis, shed light on the controversial processes that have influenced psychiatric diagnosis.
Dr. Davies begins by questioning Robert Spitzer, a pivotal figure in the DSM’s evolution, about the rationale behind the significant expansion of the DSM during his tenure. Spitzer justifies the inclusion of 80 new mental disorders, explaining that many were diagnoses already used by clinicians but lacked recognition in the DSM. Surprisingly, Spitzer acknowledges that most mental disorders lack clear biological causes, challenging conventional expectations of psychiatric diagnoses.
Further probing reveals that the inclusion of disorders in the DSM is determined by consensus rather than scientific evidence. Spitzer acknowledges that agreement among clinicians plays a crucial role in adding new categories to the DSM. This leads to a critical question: Why should the agreement of a group of psychiatrists be considered valid scientific proof?
Dr. Davies introduces the case of Paula J. Kaplan, a psychology professor, and consultant to DSM-III, who opposed the inclusion of Self-Defeating Personality Disorder (SDPD). Kaplan argued that SDPD could pathologize female victims of violence, a concern dismissed by Spitzer and the DSM committee. The questionable research supporting SDPD’s inclusion further highlights the arbitrary nature of decision-making.
Dr. Davies explores the insufficient research basis for including disorders in the DSM, quoting Dr. Theodore Millan, a member of the original task force. Millan admits to the lack of systematic research and acknowledges the scarcity of solid scientific evidence supporting DSM decisions. Shockingly, Spitzer concedes that many disorders were added without a robust research foundation.
The revelation of voting as a method to decide on DSM inclusions raises concerns about the scientific rigor of the process. Dr. Davies interviews other task force members, including Professor Donald Clime and Dr. Henry Pinsker, who confirm that decisions were often reached through voting rather than rigorous scientific analysis.
The impact of DSM-III on global psychiatry is discussed, emphasizing how Spitzer’s categories became the foundation for international research. However, Dr. Davies questions the validity of a small group, the DSM committee, shaping the entire field of psychiatry.
Transitioning to DSM-IV, Dr. Davies interviews Dr. Alan Francis, who claims the manual aimed for modesty and conservatism. However, the inclusion of disorders in the appendix challenges this assertion. Francis admits that even minimal changes to the DSM can lead to unintended consequences in its application.
The pharmaceutical industry’s influence extends to the creation of diagnostic criteria and also to the dissemination of the DSM itself, further promoting overmedicalization. The tactics employed, whether direct or indirect, serve the industry’s interests in expanding the market for psycho-pharmaceutical medications.
The second example of indirect influence delves into the heart of the British National Health Service (NHS). Two widely used documents, the PHQ-9 and GAD-7, have played a pivotal role in determining whether patients are diagnosed with anxiety or depression. Astonishingly, these documents, which have set a relatively low threshold for diagnosing mental disorders and subsequently prescribing medications, were developed, funded, and copyrighted by Pfizer Pharmaceuticals. The conflict of interest here is striking, as Pfizer stands to profit significantly from the sale of anti-anxiety and antidepressant drugs. This highlights a troubling intertwining of pharmaceutical interests with the diagnostic tools employed in routine medical practice.
The third example brings the influence of DSM into the realm of publishing. Six months after the release of DSM-5, the highest-selling book in the United States was none other than the DSM-5 itself. This seemingly inexplicable popularity becomes clearer when considering the anecdotal evidence that the pharmaceutical industry was purchasing DSM-5 in bulk and distributing it for free to clinicians across the country. The motive is apparent – by ensuring that more clinicians have access to the manual, the industry contributes to the medicalization of a broader spectrum of conditions, subsequently expanding the market for psychiatric drugs.
These examples collectively highlight the multifaceted and intricate ways in which the pharmaceutical industry exerts its influence on the psychiatric landscape. From shaping diagnostic criteria to influencing the tools used in clinical assessments and even controlling the distribution of key reference materials, the industry plays a significant role in steering the narrative towards overmedicalization. As we navigate this landscape, it becomes increasingly crucial to scrutinize the relationships between pharmaceutical companies and the various facets of the psychiatric field to ensure transparency, objectivity, and, most importantly, the well-being of the individuals who may be affected by these diagnostic decisions.
The lecture spotlights the intersection of pharmaceutical interests and everyday medical practice, particularly in psychiatry. The extensive financial ties between pharmaceutical companies and academic psychiatry have not only influenced research but also exerted a significant impact on training and practice. This influence is manifested through various channels, including departmental income, personal income from clinical trials, research funding, consultant fees, speaker fees, and honoraria received by academic drug researchers.
A critical observation is that the pharmaceutical industry has played a substantial role as a major financial sponsor for both UK and US academic psychiatry. Notably, the lecture points out that the pharmaceutical industry’s support extends to heads of psychiatry departments receiving departmental income from drug companies. Simultaneously, many clinical trials into psychiatric drugs, including antidepressants, neuroleptics, and tranquilizers, are financially backed or commissioned by these pharmaceutical companies.
The lecture underscores the pervasive nature of this influence, reaching into leading psychiatric organizations such as the American Psychiatric Association (APA), which is the publisher of the DSM (Diagnostic and Statistical Manual of Mental Disorders). Operational costs of the APA are significantly supported by the industry, leading to substantial growth in annual revenues over the years.
To bring the issue closer to home, the speaker shares findings from a Freedom of Information request conducted in 2012. This request aimed to uncover the financial relationships between industry and eight leading psychiatry departments in UK universities. The data, although partial, reveals substantial amounts of money received for research funding alone, ranging from 5.5 million at the University of Newcastle to 1.87 million at the Institute of Psychiatry. While this might not seem exorbitant to some, the lecture emphasizes that such funding plays a crucial role in supporting salaries, PhD students, seminars, and other essential components of academic departments.
However, the lecture also highlights a significant gap in information. Private industry income received by faculty, such as money for consultancy work, speaker’s fees, and other honoraria, is not systematically gathered by universities. The speaker quotes a statement from Liverpool University, explaining that psychiatrists are not required to report individual payments to the university.
Moreover, the lecture points out instances of irregular reporting, where a prominent psychiatry department claimed their faculty had received no payments at all, despite evidence of senior psychiatrists reporting such payments in their published research. This lack of obligation to declare the names of individual psychiatrists and the precise levels of industry income they receive each year is deemed concerning, particularly considering the demonstrated biasing effects on clinical research and practice.
The speaker asserts that such financial ties foster professional industrial dependencies and allegiances. Notably, speaker fees, consultancy fees, and other honoraria are viewed by pharmaceutical companies as investments, expecting measurable returns. Despite this, the lecture reveals a stark reality: doctors are not legally obliged to report their financial conflicts of interest to any agency or authority in the UK, a situation deemed unacceptable by the speaker.
This extensive financial influence, as discussed throughout the lecture, raises questions about the objectivity and independence of psychiatric research and practice. The speaker contends that the pharmaceutical industry actively uses these financial ties to shape the practice and ideology within the mental health field, potentially driving up prescription rates through both overt and covert means
The lecture ends with a powerful statement, underlining the need for increased transparency and ethical standards to address the complex interplay between pharmaceutical interests and mental health practices. It calls for a reevaluation of the current state of affairs, emphasizing the potential risks posed by such financial entanglements on the well-being of patients and the integrity of the psychiatric profession.
While the specific details and regulations may differ between the UK and the US, there are overarching similarities in the relationship between pharmaceutical interests and academic psychiatry in both countries. In the United States, as in the UK, there have been concerns about the influence of pharmaceutical companies on psychiatric research, training, and practice. Here are some general observations:
- Financial Ties and Research Funding: Pharmaceutical companies have been major financial sponsors of academic psychiatry in the United States. Similar to the UK, this sponsorship often includes funding for research, clinical trials, and other academic activities. Academic institutions receive support, and researchers may receive personal income from industry-sponsored projects.
- Influence on Psychiatric Organizations: Pharmaceutical companies have historically played a significant role in supporting psychiatric organizations in the US, similar to their involvement with the American Psychiatric Association (APA) in the UK. This support can impact the operational costs and activities of these organizations.
- Conflicts of Interest: Concerns about conflicts of interest have been raised in the US, with instances of researchers and clinicians receiving consulting fees, speaker honoraria, and other financial incentives from pharmaceutical companies. These financial relationships can potentially impact the objectivity and independence of research and clinical practice.
- Transparency and Reporting: Like in the UK, reporting and transparency regarding individual financial relationships between doctors and pharmaceutical companies have been points of contention. While there have been efforts to increase transparency, including the disclosure of financial ties in academic publications, gaps and inconsistencies in reporting still exist.
- Ethical Concerns: The ethical concerns raised in the lecture about the potential biases introduced by financial relationships between academia and pharmaceutical companies resonate with broader discussions in the field of medicine and psychiatry in the United States.
It’s important to note that the specifics can vary, and regulatory frameworks, reporting requirements, and cultural attitudes toward these issues may differ between the UK and the US. However, the general themes of financial influence, conflicts of interest, and the potential impact on research and practice are shared concerns in both countries. Policies and regulations may evolve over time in response to these concerns.