Friday, December 28, 2007

New DSM Task Force Members' Ties to Pharmaceutical Companies

The latest reminder of the pervasiveness of financial entanglements among physicians and medical researchers and health care corporations comes from a story in US News and World Report. The topic was how the American Psychiatric Association is attempting to make the development of the new edition of The Diagnostic and Statistical Manual of Mental Disorders the "most transparent" ever. The impetus behind the new transparency may have been criticism that the last edition was written by a group of authors heavily financially entangled with health care corporations (see post here, based on early reports of the results of this article: Cosgrove L, Krimsky S, Vijayaraghavan M et al. Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychother Psychosom 2006; 75: 154-160, available here).

This time around, pledging to avoid even the appearance of conflicts, the APA has instituted screening procedures for the 27 members of its DSM task force, asking them for detailed financial information about stocks, honoraria, and consulting fees from drug interests.

Yet the summaries of the disclosure statements that were recently released to the public are remarkably spare [see them here]; they show only the existence of corporate connections, not their dollar amount or their duration. The result is a document that even an APA board member suggested is not very revealing. In a 2006 memo to the board obtained by U.S. News, William Carpenter wrote: 'Simple listing of all relationships is not very informative and does not identify potential conflicts that may need to be resolved.'

Critics say the limited information violates the spirit of disclosure. 'There is disclosure, and then there is disclosure,' says Daniel Carlat, a psychiatrist and former consultant to drug companies [and blogger on the Carlat Psychiatry Blog]. "There is a big difference between $500,000 and $500. It is one thing to disclose in a generic way, to say that a psychiatrist has had some consulting with a company, but that doesn't tell you a number of things.'

Furthermore, the disclosure appears incomplete in many ways. There were errors by the task force members.

Dilip Jeste, a professor of psychiatry at the University of California-San Diego, had consulting ties that did not appear on his disclosure form. Yet during the reporting year of 2003, he was a consultant to Pfizer and AstraZeneca and received honoraria from Pfizer, according to documents. Jeste called the error 'unintentional,' saying he had relied on memory. The APA said that Jeste would submit a new disclosure. APA President Carolyn Robinowitz said that task force nominees 'were on the honor system' and acknowledged that the association had made no effort to check their accuracy.

There were errors by the APA.

The APA itself erred in its public summary for Jan Fawcett, a professor of psychiatry at the University of New Mexico and chair of the DSM's mood disorders work group. The summary lists no directorships or corporate positions for Fawcett. But a 2005 sec filing shows that he was a member of the board of directors for Berman Health and Media, a company that is poised to 'exploit opportunities in the female sexual medicine industry.' [He has since resigned from the board.] The APA said that Fawcett had disclosed the connections in private filings but that its staffers accidentally omitted them from the public disclosure form.

It's funny that the errors always seem to be of omission, not commission.

Also, task force members who received funding from medical education and communication companies (MECCs), that were, in turn, funded by drug companies, did not disclose the latter funding.

David Kupfer, the task force chair, reported multiple consulting arrangements with communications companies that 'sponsored pharmaceutical meetings & editorial work.' His public form, however, does not reveal that income from two of these companies, Prescott Communications and Innovative Medical Education, came from work for Forrest Pharmaceuticals and Pfizer, respectively. The APA said Kupfer did not need to disclose the ties because he was not paid directly by drug companies.

The APA actually not only required disclosing conflicts of interests, it required that "members pledged to limit their aggregate income from pharmaceutical sources to $10,000 a year. If their income exceeded that amount, they were required to reduce it or sever ties." On the other hand, "critics say that loopholes weaken the policy. One is that task force members can undertake new financial arrangements after being appointed. Second, task force members are not asked to disclose 'unrestricted research grants,' which often go straight to one's department or institution."

Given that the reporting may have been incomplete, it is striking that 18 of 27 (two thirds of the) members of the Task Force reported financial ties to the pharmaceutical industry, and that many of these reported multiple kinds of ties, and/or ties to multiple companies. Given how influential the DSM is on the mental health practice, and given how expansions of definitions of mental illness provide new opportunities to develop costly treatments for them, it is disturbing that the group who will develop the new DSM has had such extensive past relationships with the pharmaceutical industry.

ADDENDUM (2 January, 2008) - See also coverage of this case in Integrity in Science Watch (2 January, 2008 issue when up), and PharmaLot.

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