What is the impact of financial conflicts of interest on the development of psychiatry?

In recent years the relationship between drug companies and psychiatry has received an increasing attention from physicians, scientists and the media. Some authors support the notion that this relationship is having a negative influence on clinical practice and medical education, threatening the objective and independent development of mental sciences. According to this position, psychiatrists should avoid or minimize the interaction with pharmaceutical companies (1,2). On the other hand, some professional leaders have suggested that a substantive relationship between doctors and the drug is necessary and beneficial, and that any commercial influence mediated via this relationship does not harm significantly the future of psychiatry (3,4). In the last couple of years, serious doubts have been raised about the reliability of drug trials. In a study by Perlis et al (5) on 162 randomized, double-blind, placebo-controlled trials, those involving potential conflicts of interest were 4.9 times more likely to report positive results; this association was significant only in the subset of pharmaceutical industry-funded studies. Concerns have been also expressed about the promotional tactics used by the to display the results of these studies. The medical research community has tried to address the problem by proposing measures like the introduction of a clinical trial registry. However, several studies have shown that these measures are insufficient and a more radical reform of the clinical trials regulation is needed. Conflicts of interest have also been reported in the elaboration of clinical guidelines and the definition of diagnostic entities and classifications. It has been reported that a substantial percentage of the DSM-IV panel members had a financial tie with the pharmaceutical (6). With regard to clinical guidelines, a recent comparison of meta-analyses concluded that industry supported of drugs should be read with caution as they were less transparent, had few reservations about methodological limitations of the included trials, and had more favorable conclusions than the corresponding Cochrane reviews (7). An important scientific journal has recently introduced the concept of corporate- sponsored disease, suggesting that pharmaceutical companies, with the collaboration of physicians, are increasing the number of prescriptions of certain psychotropic agents by mongering diseases (8). According to some sources, at least 10% of the physicians in Europe and the US have close relationships to pharmaceutical companies (9). In Latin America this percentage may be even higher. In the last decade, international pharmaceutical companies have created close links to local private research managing organizations in order to run multicenter drug trials with local investigators. In most of the cases the institutions sponsoring these trials are the owners of the data. In Chile, the main medical scientific societies have proposed formal guidelines for a better control of conflicts of interest (10). However, the limited awareness of the problem and the marketing strategies designed by the do not help in this attempt, and the practice of disclosure has not achieved wide currency. A worldwide collaboration between international organizations like the WPA and the World Health Organization with their national or local counterparts is strongly recommended in this area. As Helmchen pointed out (11), one of the premises of a psychiatric intervention is the trust of the patient in his therapist, in his knowledge and scientific background. Our patients cannot lose this confidence. Otherwise, the role of psychiatry, as we know it, is going to disappear. An international effort of the psychiatric community to redefine its relationship with the pharmaceutical is urgently needed. Drug companies can be of considerable benefit for the development of our profession, but only if we learn to manage this collaboration without commitments and dependencies, considering our ethical foundations and respecting the interest of our patients over any other form of interest.