Another mainstream article makes the press about corrupt doctors taking pharmaceutical industry money. The June 8 New York Times (http://www.nytimes.com/2008/06/08/us/08conflict.html?_r=1&scp=2&sq=Biederman&st=nyt&oref=slogin) reported on a US Senate investigation into poor disclosure of millions of dollars in income provided by pharmaceutical companies to Harvard child psychiatry researchers at Massachusetts General Hospital (MGH). Like Dr. Peter Kramer ("In Practice" blog http://blogs.psychologytoday.com/blog/in-practice/200806/drug-research-and-financial-bias), I too have carefully followed the work of the MGH research group, both for their research on childhood bipolar disorder (with which I agree in large part) and their research on ADHD in adults (with with I disagree in general). Regarding treatment, my own experience and research has tended to be opposite to theirs: I have found amphetamine stimulants (especially methylphenidate) and antipsychotics to be less effective and more harmful than they have reported. Has their optimism about medications been biased by their profits? Perhaps; perhaps not. There are plenty of profits to go around, and just as much can be made these days bashing medications as marketing them.

Consider this new genre of books: Overdosed America: The broken promise of American medicine; Comfortably Numb: How psychiatry is medicating a nation; The loss of sadness: How psychiatry transformed normal sadness into disorder; The medicalization of society: On the transformation of human conditions into treatable disorders; Against happiness: In praise of melancholy; Overtreated: Why too much medicine is making us sicker and poorer; Selling sickness: How the world's biggest pharmaceutical companies are turning us all into patients; The truth about the drug companies: How they deceive us and what to do about it.

Okay. We get it.

I see no books defending the pharmaceutical industry, or the principles of capitalism, for that matter. Not that I would argue for such tomes, but the sheer number and vigor of this current trend suggests we pause a moment. Let me preface my comments by saying that I agree with the gist of many of these critiques: The pharmaceutical industry can, and has, overmarketed drugs and reaped excessive profits for some marginally effective or questionably safe medications. And, academic medicine can be, and has been, complicit in some of these practices. This needs to change.

However, I wonder whether we will get the change we need from a one-sided, adversarial approach. Further, the logic behind the specific focus on the pharmaceutical industry is not entirely obvious to me.

Is the problem profits per se? If so, we are left with this dilemma: we like capitalism in principle, but we dislike it in practice - or at least in medical practice. Maybe that's the answer: perhaps medicine should not have a profit motive; it should be cleansed from any capitalist basis. So....socialized medicine? Like Canada?

No, that seems too radical. But why pick on the pharmaceutical industry, and let other forms of profit go? How about the profits generated for authors and the book industry from all those books? Is there a conflict of interest there? Or how about the profits in the private practice of medicine? If research doctors are corrupt because they are making millions of dollars from their links to the pharmaceutical industry, how is that different from those private practice doctors in Beacon Hill, and Park Avenue, and indeed on Main Street, making millions of dollars in their practice of medicine for money? Should we join our British cousins? Let doctors get salaries from the government - let us remove all exchange of fees, and turn medicine into a purely non-profit craft.

I personally would not fear such an outcome, and some critics of the pharmaceutical industry - like Physicians for a National Health Program - have proposed it. Such honesty would be refreshing, in fact. Let all the researchers give up their consulting fees; and let all the private practice doctors give up their clinical fees.

But we seem too liberated for such a solution. We should, some critics seem to say, stop some people from making profits, while letting others proceed.

The illogic of this critique suggests we need to approach this problem with less moralizing, and more pragmatism. What exactly is the problem that concerns us?

Here I have to add a second preface: My further comments stem from my own experience as a psychopharmacology researcher, one who has done research funded by pharmaceutical companies, and who has received income from speaking fees for those companies. Further, I know the specific persons mentioned in the NY Times article personally, having been their colleague for a time at Massachusetts General Hospital and in Harvard. Perhaps this personal background introduces some bias, but it may also allow me some insights:

The problem of money and academics is complex. On the one hand, the public and our profession supports research; we are told research is a good thing. On the other hand, the federal government (the NIMH) provides very little money for research (at least in clinical psychiatry). Thus if funds from the pharmaceutical industry are not used, we will have less research. Perhaps we are willing to accept this result; but we need to be clear that it would follow. Further, hospitals and universities encourage research because they earn money from it, whether it is NIMH funded or pharmaceutical industry funded. If we stop such research, hospitals and universities would have more economic problems; again, perhaps we will accept this, but we need to know it could happen. Reality: the average academic researcher makes about 1/3 less income than the average non-academic physician. The extra income made by lecturing for pharmaceutical companies usually brings academic incomes to the norm of most doctors; usually academics do not get rich, they simply join their peers, with such income. If such extra funds are stopped, we will incentivize fewer doctors to become researchers. Many will continue to do so, due to their scientific commitment to knowledge, but some may not be able to do so for financial reasons; perhaps we can accept this, but this too can be a result of cutting the connection between the pharmaceutical industry and research.

The problem of conflict of interest is even more complex: One book says we should just follow the money. I suppose Karl Marx would agree. He has a point, but if matters were this simple, Leningrad would now be the capital of the free world. I have found that it is generally a bad idea to try to infer others' intentions. Humans do things for many reasons, most of which are opaque to us; the driving force is sometimes money, sometimes prestige, fear, lust, insecurity. It is hard to tell why people do what they do. If I had to guess which motivation matters most, I would say prestige rather than money. In any case, it is not straightforward to infer bias based on receiving income from the pharmaceutical industry. Why are not such inferences made in all those books-for-profit written in critique of the pharmaceutical industry?

There is corruption: some academics have made excessive profits and have been biased in their research and teaching. Some pharmaceutical companies have done likewise. There is a need to clean up this relationship. But I believe we should turn to the substance of what is at issue, rather than inferring motivations or judging others' ethics. Let us look at the actual research that is being done, critique the stands that academics take, and apply valid scientific standards to claims that are made. And let us set up and enforce policies that keep academic-pharmaceutical industry relations within reasonable bounds, while at the same time providing more government funds for research.

I will write much more about this topic; it is too large and too hot to handle briefly. But for now let me end with a personal conversation I recently had with a prominent psychiatric researcher who also has been the target of media criticism for his pharmaceutical ties; he dismissed it all as a "witch hunt." I think he was in the wrong on a number of matters and that he overhyped certain medications. I have published my critiques of those specific issues of substance and I have lectured and taught about them widely. So I do not agree with him. But, humans have many faults, and being judgmental is one of them. This is not just a witch hunt, but it can easily degenerate into one.