Non-financial conflicts of interests in psychiatric research and practice

Not all conflicts of interests affecting psychiatry are financialin nature. Our field is vulnerable to some varieties of nonfinancialconflicts of interests. Examples include the possible conflictbetween a researcher’s allegiance to a school of thoughtand the integrity of psychotherapy research, or between a psychiatrist’spolitical commitment and patients’ welfare.

INTRODUCTION

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INTRODUCTION

Conflicts of interests occur when doctors are unduly influencedby a secondary interest (i.e. a personal incentive) in theiracts concerning one of the primary interests to which theyare professionally committed. These primary interests are:the welfare of their patients, the progress of science (ifthey are researchers), and the education of their students,residents or colleagues (if they are scholars). The secondaryinterests that may unduly influence doctors’ actionsinclude: financial gain for themselves or for an institution;personal recognition, career advancement or visibility in the media; bestowing favour on a relative, friend or colleague;the allegiance to a school of thought; and political commitment.^1,2

Of the conflicts of interests that may occur in medical (andpsychiatric) research and practice, one specific variety haspredominantly attracted the attention of the scientific andgeneral press: financial conflicts of interests arising fromrelationships between physicians and drug companies. Thereis growing empirical evidence of the significant impact theseconflicts have on psychiatric research and practice.^3–5 The suspicion is warranted that current research evidence inthe field of psychopharmacotherapy is, to some extent, biaseddue to the impact of these conflicts, and that clinical practiceis consequently misdirected.

However, not all financial conflicts of interests affectingpsychiatric research and practice arise from psychiatrists’relationships with the pharmaceutical industry.^6,7

In research, the same overt or subtle influence that has beendescribed on the design, conduct, analysis of data and reportingof results of trials supported by drug companies may be alsoat work in trials funded by public agencies with an interestin promoting the use of the cheapest medications. This mayoccur especially if the publication of results in line withthe sponsor’s interest is likely to improve a researcher’schance of future funding. Some trials comparing new-generationwith old-generation drugs may have been affected by this kindof conflict.

In clinical practice, doctors, including psychiatrists, arenow increasingly pressured by their hospital administrationsto be ‘productive’ (i.e. to see as many patientsas possible in their working time) and to use the least expensivetreatments. This ‘productivity’ and use of thecheapest interventions is often not in the best interests ofpatients. If a financial incentive is involved, a conflictof interests may occur.

In addition, not all conflicts of interests affecting researchand practice are financial in nature. Our profession is particularlyvulnerable to some forms of non-financial conflicts of interestswhich deserve some discussion.

The ‘allegiance effect’ in psychotherapy research

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The 'allegiance effect' in...

An example of a non-financial conflict of interests affectingpsychiatric research is given by the possible conflict betweenthe secondary interest represented by the researcher’sallegiance to a given school of thought and the primary interestrepresented by the progress of science.

The impact of this ‘allegiance effect’ on the outcomeof psychotherapy research has been repeatedly described. Asystematic review⁸ found that the combination of three measuresof researcher’s allegiance accounted for 69% of the effectsize of treatment outcome in studies comparing three psychotherapeutictechniques. Interestingly, some mechanisms by which the researcher’sallegiance may operate are very similar to those explaining the impact of financial conflicts of interests on the outcomeof drug trials: selection of a less effective interventionto compare with the researcher’s favoured treatment;unskilful use of the comparison treatment; focusing on datafavouring the preferred treatment in study reports; and failureto publish negative data.

Along with the fact that the proponents of some specific psychotherapies may, for various reasons, be less interested in the scientificvalidation of their techniques, this allegiance effect maybias the evidence concerning the relative efficacy of the variouspsychotherapies – exactly like the impact of financialconflicts of interests may bias the evidence concerning therelative efficacy of the various psychotropic drugs. Not surprisingly,it has been argued that ‘the balance of investigatorallegiance across the schizophrenia literature is against psychodynamicor supportive methods and in favour of cognitive–behaviouraltherapy approaches’.⁹

Psychotherapy research may also be affected by financial conflictsof interests; for instance, if the researcher who focuses ondata favouring a given treatment in study reports or who failsto publish negative data is the owner of a private school ofpsychotherapy.

Psychiatrists’ political commitment and patients’ welfare

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Psychiatrists' political...

An example of a non-financial conflict of interests affectingpsychiatric practice is given by the possible conflict betweenthe secondary interest represented by a psychiatrist’spolitical commitment and the primary interest represented bypatients’ welfare.

I live and work in a country in which a minister of educationstated some years ago that a psychiatrist should always bea political activist. Indeed, being so may be very useful topsychiatrists in fulfilling their professional duties. Thisapplies, in particular, to the practice of community mental healthcare: being a political activist may mean that a psychiatristhas regular contact with several community agencies which mayfacilitate patients’ social inclusion. However, it isa fact that some political credos are often associated witha strong prejudicial attitude against the use of medicationsin psychiatry and the hospitalisation of psychiatric patients. This attitude may sometimes amount to fanaticism, with theexpression of sentiments such as ‘those who prescribepsychotropic drugs are like pushers’ or ‘psychiatrydoes not need any beds’.

Of course, everybody is free to hold and profess even extremeideas, and one could argue that these views may sometimes representa stimulus to the field. However, if a psychiatrist holdingsuch ideas (or, even worse, a psychiatrist wishing to pleasea senior consultant or a manager holding such ideas) deniespharmacological treatment and/or hospitalisation to a severely depressed patient, who then dies by suicide, is this not atragic instance of conflict between the secondary interestrepresented by the psychiatrist’s political commitmentand the primary interest represented by the patient’swelfare?

A prejudicial attitude against the use of medications in psychiatrymay more often manifest itself as the stubborn refusal to learnto use them adequately and to even consider reading drug treatmentguidelines, because this would mean acknowledging the essentialtherapeutic role of something which is, instead, regarded asonly a marginal ingredient of care. The consequence of thisattitude is that medications are used, but in an irrationaland chaotic way, again with significant detriment to patients’welfare.

Special interest groups

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Special interest groups

It has been rightly pointed out¹⁰ that there are now in ourfield ‘special interest groups’, consisting of prominentopinion leaders with significant financial conflicts of interests (arising from their relationships to drug companies), who exercisea powerful impact on the field in their various capacities(e.g. as editors or referees of scientific journals, or ascontributors to treatment guidelines). One could argue, however,that similar special interest groups may also exist, consistingof prominent leaders with significant non-financial conflictsof interests arising from their strong political commitment.They may exercise an equally powerful impact on our field acting,for instance, as contributors to mental health policy guidelinesor consultants to governments. Moreover, when acting as refereesfor scientific journals or evaluating research projects submittedto public agencies, they may be biased against sponsored drugtrials or unfairly favour colleagues who share their politicalcredo.

It is probably useful to mention one more emerging circle, thatof ‘two-sided’ experts, eloquently advocating oppositepositions (for instance, being for or against the use of new-generationmedications) depending on the context in which they speak (e.g.a sponsored symposium v. a meeting of a governmental task force).

Conclusion

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Conclusion

It is beyond the scope of this editorial to list what can bedone to address the issue of financial and non-financial conflictsof interests in psychiatric research and practice. One pointI would like to make, however, is that awareness of their existenceand their impact on our field is a first, necessary step. Thereis today an acute and welcome awareness of the impact of financialconflicts of interests arising from psychiatrists’ relationshipswith drug companies. The same cannot be said for non-financial conflicts of interests.

Is the fervent allegiance to a given school of thought or anactive political militancy, in itself, something bad or inappropriatefor a psychiatrist? Certainly not. Is being a consultant toa drug company in itself immoral or unethical? Again, it isnot. Both can be useful to psychiatrists in the fulfilmentof their professional duties. However, as far as they may collidewith the primary interests represented by the patients’welfare and the progress of science, both may be a source ofconflicts of interests. It is not uncommon to discover thatthose people who are very vociferous in denouncing one typeof conflict of interests are particularly susceptible to another.

REFERENCES

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