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4. ‘Mental health’ is defined and controlled by profit-driven commercial interests

    The real story of psychiatry

    Mental illness is ‘big business’ for psychiatry and pharma

    For decades, psychiatry in collusion with pharmaceutical companies and to a lesser degree device manufacturers, has turned the subject of mental health into a for-profit free-for-all where patients have become repeat customers.

    This influence extends right across the activity including determining trends of research, and research results, defining mental illness to academia and the public, training psychiatrists, influencing drug prescriptions through clinical guidelines, etc, etc.

    ‘Mental health’ is only what psychiatry and pharma marketing campaigns want to say it is, ignoring inconvenient facts such as the cause of mental illnesses are never found and no one is ever actually cured.

    “This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies…”

    Loren Mosher, former chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health, USA. 1998

    In 1998 Loren Mosher, the former chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health USA resigned from the American Psychiatric Association (APA) in frustration:

    “This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds luncheons, unrestricted educational grants etc. etc. Psychiatrists have become the minions of drug company promotions…No longer do we seek to understand whole persons in their social contexts rather we are there to realign our patients’ neurotransmitters.”

    Loren Mosher. 1

    Never finding cures mean billions in drug profits

    A world of mass-produced pharmaceuticals

    In 1897, the German chemical giant Bayer found a new way to produce what would become Aspirin and by 1899 were selling the drug globally under a trademarked name – the world had entered the age of mass-produced pharmaceuticals. Soon there was a realization of the enormous profits such drugs could provide to their manufacturers.

    Although it took 50 years of serendipity for psychotropic drugs to be ‘discovered’, these drugs have become some of the most profitable of all time.

    In 2021 the global sales of antipsychotic drugs were estimated at $14.54 billion and increased at a yearly rate of 6.9%.

    The global sales of psychiatric drugs for things such as depression, anxiety, and obsessive-compulsive disorder have been estimated at more than $27 billion in 2020 and growing at an annual rate of 8.4%. 2

    Profits depend on patients being ‘repeat customers’

    If psychiatry and the pharmaceutical industry would provide cures for the mentally ill then billions in drug profits would dry up. Cures are something they have not provided.

    Flying Logos, CC BY-SA 4.0, via Wikimedia Commons

    None of these billions in drug sales provide cures for people who are mentally ill. They merely suppress symptoms but more than that, they provide a perpetual stream of patients who then rely on repeated use of the drugs.

    Both the pharmaceutical industry and psychiatry are now dependent on patients remaining as repeat customers.

    With more and more symptoms being added for which drugs are prescribed through things like the Diagnostic and Statistical Manual (DSM) and the fact that the drugs are extremely difficult to come off, then you have a corrupt and quite immoral manipulation of what should be a vital public service, for the sake of drug profits.

    The Sunshine Act: a strong enough disinfectant?

    The effect of conflicts of interest between pharmaceutical companies and medical practitioners, including psychiatrists, had become so severe that the Physician Payments Sunshine Act (PPSA) covering all branches of medicine was made law and came into effect in the United States in 2013. 3

    In terms of psychiatry, the act includes the full disclosure of all conflicts of interest in an attempt to bring to light the corruption of psychiatry practices, teaching, and research by complicit psychiatrists, the pharmaceutical industry, and device manufacturers.

    Similar codes of conduct requiring disclosure of conflicts of interest have been enacted in other countries.

    Whether the act will be sufficient to bring about adequate change in this area, in many cases where the immoral, even criminal, is seen as normal, has yet to be seen.

    “We analyzed five signal cases, all involving psychiatrists, that Grassley (U.S. Senator Charles Grassley) presented to the U.S. Senate as examples of why PPSA (Physician Payments Sunshine Act) was needed. We sought to determine the impact of the information Grassley brought to light on the physicians who failed to report their industry ties and on the medical institutions responsible for overseeing their conduct. Despite the clarity of the violations and the powerful actors and institutions involved, the consequences of exposure were slow to materialize and limited in their impact.”

    Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry: does transparency matter? Int J Law Psychiatry. 2012 4

    And if the Sunshine Act does fail, the place to start any investigation as to why could be:

    In 2020, two-thirds of the membership of the US Congress (Senate and House of Representatives) cashed checks from pharma as part of their campaign funding. 5

    Similarly, at least 2,467 US state legislator campaigns were also funded by pharma, as part of the 2020 election cycle. Over 10,000 individual checks totaling more than $9 million. 6

    The extent of the psychiatric/pharma collusion

    A 2020 study of pharmaceutical industry payments to psychiatrists in just the US alone for 2016/2017 found that 55.7% of psychiatrists were receiving payments from the pharmaceutical industry. This was $110,512,607.18 paid to 26,422 psychiatrists. These payments were from more than 360 different pharmaceutical or device manufacturing companies. 7

    Considering that this type of payment is also occurring in all relatively advanced countries at least, adding in donations to political parties and politicians, universities and opinion leaders, and large media budgets, the subject is being subjected to an enormous well-funded campaign to manipulate the state of mental health.

    Commercial Influence on the Diagnostic and Statistical Manual (DSM)

    DSM 4 and DSM 5 books

    The American Psychiatric Association’s very influential Diagnostic and Statistical Manual of Mental Disorders (DSM) and particularly DSM version III published in 1980, reflected a dramatic move toward biological psychiatry that resulted from the ‘discovery’ of psychotropic drugs from the mid-1950s forward.

    By the time work was being done on DSM III, antipsychotics were entering broad use (and of course, this was later followed up by the ‘blockbuster’ antidepressants of the 1980s.) The changes introduced by DSM III formed the basis for all later editions too.

    Yet, so nonchalant was the American Psychiatric Association about the influence of commercial interests on the Diagnostic and Statistical Manual of Mental Disorders that they had no conflict of interest policy for DSM III, i.e. required no declaration of interests.

    Nonetheless, in the late 1990s, Robert Spitzer the head of the DSM III Task Force and consulting on later versions is reported to have been personally paid $21,000 (almost $50,000 in today’s money) by the drug manufacturer Pfizer for speaking engagements promoting the company’s drugs. Pfizer was also a major sponsor of the New York State Psychiatric Institute drug experimentation where Spitzer worked. Further indications of the ethical environment where Spitzer worked include the institute’s deputy director in the 1990s had taken home $140,000 in pharmaceutical company payments in a single year. 8

    Regarding conflicts of interest in Dsm IV, Spitzer made this statement to Bloomberg News in 2006:

    “Of course, these experts have a relationship” with drug companies, Spitzer said in a telephone interview today. “If you’re an expert in schizophrenia, you’re almost certainly going to be asked to either consult or give a talk which is paid for. But what’s the conflict?”

    Robert Spitzer, head of the DSM III task force.Bloomberg News. 2006.

    Despite Spitzer’s nonchalance regarding the effect of conflicts of interest, he was well aware of the result:

    “Spitzer acknowledged that many academic psychiatrists double or triple their incomes with funding from the drug industry, undermining trust in the results of drug research. ‘There is a crisis of confidence in the reliability of drug trials because of the undue influence of the pharmaceutical industry,’ he said.”

    Robert Spitzer, head of the DSM III task force.Bloomberg News. 2006. 9

    For versions of the Diagnostic and Statistical Manual of Mental Disorders after III, there is considerably more data but no less disturbing.

    In 2006, work by Lisa Cosgrove (University of Massachusetts)  and Sheldon Krimsky (Tufts University) found that for DSM IV (still no declarations of conflicting interest required but information discovered):

    “Of the 170 DSM panel members, 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16I%).”

    And from the conclusions of their study: “The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.”

    Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L. Financial ties between DSM-IV panel members and the pharmaceutical industry. 10

    For DSM V published in 2012, Lisa Cosgrove and Sheldon Krimsky found an even worse situation:

    “Currently, 69% of the DSM-5 task force members report having ties to the pharmaceutical industry. This represents a relative increase of 21% over the proportion of DSM-IV task force members with such ties (57% of DSM-IV task force members had ties).” … “Three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry.”

    Cosgrove L, Krimsky S, A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists.11

    And if it wasn’t pharma’s influence over the DSM, then it certainly wasn’t science! The authors of DSM III admit the document was written based on their opinions and little if any science.

    DSM 4 and DSM 5 books

    Psychiatry’s DSM – just a bunch of opinions

    Psychiatry’s influential Diagnostic and Statistical Manual of Mental Disorders is only based on the consensus of opinions of a small number of American Psychiatric Association psychiatrists, rather than science. The ‘neo-Kraepelin revolution’ of unproven …

    Commercial influence on clinical practice guidelines

    Another immediate area of concern is regarding Clinical Practice Guidelines, i.e. going beyond diagnosis to what do you then do about it. This is an obvious area where any conflicts of influence could occur as the guidelines give exact procedures and treatment including what drugs and devices to use.

    Still, in the US, a 2009 study found that of the 20 authors of major practice guidelines ( schizophrenia, bipolar, and major depressive disorder MDD) 18 (90%) had at least one financial relationship with the pharmaceutical industry.

    “Of the 18 workgroup members [authors] who had industry relationships, 77.7% received research funding, 72.2% were consultants, 44.4% were on corporate or advisory boards to companies, 38.8% received honoraria, 33.3% served on company speaker’s bureaus, and 16.6% held equity in a drug company that manufactured the drugs identified in the practice guidelines.”

    L Cosgrove. et al. Conflicts of Interest and Disclosure in the American Psychiatric Association’s Clinical Practice Guidelines. 12

    Psychiatrists as part of Speaker Bureaus for pharma

    Psychiatrists were and are appearing on highly paid pharmaceutical ‘advisory boards’ and ‘speaker bureaus’, i.e. advising and taking part in marketing to forward commercial interests, both their own and the pharmaceutical companies.

    In looking for examples, from 1987 – the release of the first mass antidepressant, Prozac, forward – searching Google Scholar using search terms “speakers bureau” and “depression” returns 13,900 results and examples aplenty. For the same time period, the search terms “advisory board,” “depression” and “remuneration” returned 3,600 results. 13

    “It boggles my mind,” said Dr. James H. Scully Jr., chief executive of the American Psychiatric Association, referring to the big money paid to some psychiatrists for what are billed as educational talks.

    Paid speaking “is perfectly legal, and if people want to work for drug companies, this is America,” said Scully, whose specialty has often been criticized for its over-reliance on medications. “But everybody needs to be clear — this is marketing.”

    Salon. 2013. 14

    Influence on medical schools and psychiatric training

    Another aspect of the enormous challenge in returning any semblance of scientific credibility to psychiatry is the influence of commercial interests, pharmaceutical companies, and device manufacturers, in the training of psychiatrists.

    Not only are the future members of the profession being told what to think by these commercial interests but commercial domination of the subject is being presented as the norm.

    “The pharmaceutical industry currently plays an extensive role in teaching psychopharmacology to trainees, both directly and indirectly. Attendance at industry-sponsored lectures and drug lunches, meetings with pharmaceutical representatives, and interactions involving the acceptance of various gifts are the most obvious venues. Less apparent but equally pervasive are the influence of industry-sponsored faculty and research and industry’s effect on the climate of practice and the profession as a whole. Replacing medical education with industry promotion in the guise of scholarship causes demonstrable harm to trainees, the public and the profession.”

    Amy C. Brodkey M.D. The Role of the Pharmaceutical Industry in Teaching Psychopharmacology: A Growing Problem. 15 16

    The assault on any science of mental health

    Suppression and manipulation of scientific information and trial results

    The ‘science of mental health’ is entirely what commercial interests and colluding psychiatrists say it is and permit to be known.

    One of the most damaging effects of collusion between psychiatry and pharmaceutical companies/device manufacturers is the suppression and manipulation of scientific information and trial results.

    What is ‘science’ is being determined not solely through the domination of what experimentation is being done but how it is being done and then through stringent controls of what information is then published or otherwise made public.

    The ‘science of mental health’ is entirely what commercial interests and colluding psychiatrists say it is and permit to be known.

    An extensive examination of the unscrupulous methods used can be found in the Yale University School of Medicine paper Promoting Transparency in Pharmaceutical Industry–Sponsored Research by J Ross, C Gross, and HM Krumholz. 17

    The paper is based on actual instances of scientific data corruption, not the ‘possibility of’ or chance, and in many instances obtained from records released as part of legal actions that would not have otherwise ever been made public.

    “Industry has used seeding trials, publication planning, messaging, ghostwriting, and selective publication and reporting of trial outcomes to distort the medical literature and undermine clinical trial research by obscuring information relevant to patients and physicians.”

    Ross JS, Gross CP, Krumholz HM. Promoting transparency in pharmaceutical industry-sponsored research. 18

    The paper found several repeating patterns of scientific corruption:

    Seeding trials – where trials are apparently done to further scientific investigation however whose planned existence and results were merely directing attention as part of product marketing campaigns

    Publication planning – the planning for the writing and release of medical journal articles timed and shaped to forward the release and marketing of commercial properties.

    Key messaging – designing ‘scientific’ results and papers around ‘key messaging’ found by marketing that would enhance the sales of a drug or device.

    Ghostwriting – clinical trial results and papers that have been written by employees of commercial interests, whose involvement is completely obscured by the assignment of academics as the fraudulent source.

    Guest authorship – designation of an academic as an additional author of a paper or trial result with no actual involvement, but merely to add credence to the trial or paper.

    Selective publication – delayed publication or nonpublication of clinical trials that may have an adverse effect on commercial properties.

    Selective reporting – partial or incomplete reporting of clinical trial findings that may adversely affect the value of a commercial property.

    Ambiguous reporting – reporting clinical trials that are adverse to commercial interests in a fashion that misleads or will not bring attention to them.

    The data here is a short summary of what can be found in the Yale Medical School study and it is thoroughly recommended to study the complete paper and examples therein.

    Conflicts of interest bias trial results

    An extensive review of clinical trials from 2005 found that when psychiatrists and other researchers had existing commercial conflicts of interest with pharmaceutical companies the results were found to be 4.9 times more likely to report positive results for those pharmaceutical companies than researchers with no such conflicts

    And to show some estimate of the extent of this problem, 60% of 397 studies chosen for review were found to have the authors with a conflict of interest toward a pharmaceutical company.

    “Among 397 clinical trials identified, 239 (60%) reported receiving funding from a pharmaceutical company or other interested party, and 187 studies (47%) included at least one author with a reported financial conflict of interest. Among the162 randomized, double-blind, placebo-controlled studies examined, those that reported conflict of interest were 4.9 times more likely to report positive results; this association was significant only among the subset of pharmaceutical industry-funded studies”

    Roy H. Perlis, et al.Industry Sponsorship and Financial Conflict of Interest in the Reporting of Clinical Trials in Psychiatry 19

    Ghostwriting polluting the research record

    “The practice of ghostwriting is neither rare nor harmless. Alleged ghost authors haunt the clinical trial literature of virtually all the recent blockbuster drugs,…”

    Why Does Academic Medicine Allow Ghostwriting? A Prescription for Reform.

    It is now common practice for pharmaceutical companies to ‘ghostwrite’ articles providing an endorsement of their product and to have it signed by psychiatrists, leaving the actual extent of the commercial company involvement in the article hidden.

    “The practice of ghostwriting is neither rare nor harmless. Alleged ghost authors haunt the clinical trial literature of virtually all the recent blockbuster drugs, including medicines like Vioxx, Avandia, Paxil, Zoloft, Zyprexa, hormone-replacement therapy, and Fen-phen. As the makers of these drugs are embroiled in product liability lawsuits from their product’s tendency to cause harm, the involvement of ghostwriters in the production of scientific evidence to support their use has raised eyebrows.”

    Jonathan Leo, Jeffrey R. Lacasse & Andrea N. Cimino. Why Does Academic Medicine Allow Ghostwriting? A Prescription for Reform. 20

    There are dozens of professional ghostwriting companies offering services to scientists and researchers. A researcher who might want help writing up a paper hires a company to assist him in doing so – turning his ideas and notes into publishable form. The researcher’s name goes on the paper and it is a valid representation of his work. Not too much wrong with that.

    Now, let’s see a possible psychiatry version:

    A pharmaceutical company had developed a drug that can suppress a symptom of a mental illness – at least the company wants to say it can.

    The marketing department calls for peer-reviewed literature promoting the use of the drug and how it can handle the symptom. The company’s ghostwriters get going and write a paper promoting the use of the drug. The company looks over the psychiatrists who are already on the company’s ‘advisory board’ or ‘speaker bureau’ for the drug, i.e. already being paid by the company, or otherwise finds one who is an opinion leader in the field. The psychiatrist’s name is added to the paper and it is published. There is no indication at all that the actual author of the paper was a pharmaceutical company employee. The ‘opinion leader’ psychiatrist may never have seen the original research data or even read what he is now said to be authoring.

    ‘It’s a prostitution of their academic standing. And it undermines the integrity of the entire academic publication system…”

    Trudo Lemmens. University of Toronto professor of law and medicine. 21

    Or variations, such as the psychiatrists being given what data from research the company wants to promote (good data put forward, bad data suppressed). The psychiatrists then write up the paper ONLY based on the information provided to them by the pharmaceutical company.

    Without cooperation from the company and the psychiatrist, this type of ghostwriting is almost impossible to detect. Where it has been detected is in the courts where the company was being asked to prove the veracity of this or that research paper and has been required to provide original documents. The fraud then becomes clear.

    Ghostwriting case studies

    A few case studies, from the paper by Leemon McHenry, Dept of Philosophy, Florida State University, California State University, Northridge, USA. 2010: Of Sophists and Spin-Doctors: Industry-Sponsored Ghostwriting and the Crisis of Academic Medicine 25 :

    ‘A study of documents released from litigation against Pfizer’s SSRI antidepressant Zoloft showed that a medical communication company, Current Medical Directions, was preparing, on behalf of Pfizer, 85 papers for publication. 55 of these papers appeared in the leading medical journals between 1998 through 2000 (Healy and Cattell, 2003). In the published articles, there was a consistent emphasis on the positive profile of Zoloft and an under-reporting of side effects.’

    ‘A study of released documents in a legal case involving marketing the SSRI antidepressant paroxetine for adolescent depression revealed that a pivotal clinical trial conducted by SmithKline Beecham, study 329, was ghostwritten by a medical communications company, Scientific Therapeutics Information. The resulting publication by Martin Keller et al. in the Journal of the American Academy of Child and Adolescent Psychiatry (Keller et al. 2001) manipulated the data to make it appear that the trial was a success when, in fact, it failed both requirements for efficacy and safety (Jureidini et al. 2008).’

    ‘A study of released documents in a legal case involving failure to warn of withdrawal side effects of the SSRI antidepressant paroxetine showed how SmithKline Beecham engaged the public relations firm, Ruder Finn, to write letters to the editor of The Journal of Clinical Psychiatry using key opinion leaders as the ‘authors’ of the letters (McHenry, 2005). Several letters were prepared by ghostwriters at Ruder Finn defending paroxetine under names of different ‘authors.’ ‘

    University of California, San Francisco, Drug Industry Documents

    The University of California, San Francisco provides an extensive archive of drug industry documents with 99 search result pages on the topic of ghostwriting.

    Journals have to battle for the truth

    ‘We are being hoodwinked by the drug companies. The articles come in with doctors’ names on them and we often find some of them have little or no idea about what they have written,’

    Dr Richard Smith, former editor of the British Journal of Medicine

    Scientific journals are in a continual battle with pharmaceutical companies and unscrupulous medicos and psychiatrists to get truthful publications.

    “Dr Richard Smith, former editor of the British Journal of Medicine, admitted ghostwriting was a ‘very big problem

    We are being hoodwinked by the drug companies. The articles come in with doctors’ names on them and we often find some of them have little or no idea about what they have written,’

    When we find out, we reject the paper, but it is very difficult. In a sense, we have brought it on ourselves by insisting that any involvement by a drug company should be made explicit. They have just found ways to get round this and go undercover.’

    Dr Richard Smith, former editor of the British Journal of Medicine. From The Guardian. Revealed: how drug firms ‘hoodwink’ medical journals. 2003. 22

    1. Loren R. Mosher, M.D. Resignation from the American Psychiatric Association. 1998.
    2. Global Data. Global sales of psychiatric drugs could reach more than $40bn by 2025 due to coronavirus, says GlobalData
    3. Physician Payments Sunshine Act of 2009
    4. Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry: Does transparency matter?, International Journal of Law and Psychiatry 2012.
    5. More than two-thirds of Congress cashed a pharma campaign check in 2020, new STAT analysis shows. Lev Facher. www.statnews.com. 2021.
    6. Pharma funded more than 2,400 state lawmaker campaigns in 2020, new STAT analysis finds. Lev Facher. www.statnews.com. 2021.
    7. Taeho Greg Rhee, Samuel T. Wilkinson. Exploring the Psychiatrist-Industry Financial Relationship: Insight from the Open Payment Data of Centers for Medicare and Medicaid Services. Adm Policy Ment Health. 2020
    8. New York Post. 1999. State Shrinks Get Lecture Tours On Drug-makers Dime
    9. Bloomberg News. 2006. Psychiatric Manual’s Authors Have Financial Ties to Drugmakers
    10. Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L. Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychother Psychosom. 2006
    11. Cosgrove L, Krimsky S. A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists. PLoS Med. 2012
    12. Lisa Cosgrove, Harold J. Bursztajn, Sheldon Krimsky, Maria Anaya, Justin Walker. Conflicts of Interest and Disclosure in the American Psychiatric Association’s Clinical Practice Guidelines. Psychother Psychosom 2009;78:228–232
    13. Troyen A. Brennan, David J. Rothman, Linda Blank; David Blumenthal, Susan C. Chimonas, Jordan J. Cohen, Janlori Goldman, Jerome P. Kassirer, Harry Kimball, James Naughton and Neil Smelser. Health Industry Practices That Create Conflicts of Interest. JAMA, January 25, 2006—Vol 295, No. 4.
    14. Salon. 2013. Doctors paid millions to shill for Big Pharma.
    15. Amy C. Brodkey M.D. The Role of the Pharmaceutical Industry in Teaching Psychopharmacology: A Growing Problem. Academic Psychiatry volume 29, pages 222–229 (2005)
    16. Global News. 2019. Big pharma pours millions into medical schools — here’s how it can impact education
    17. Ross JS, Gross CP, Krumholz HM. Promoting transparency in pharmaceutical industry-sponsored research. Am J Public Health. 2012.
    18. Ross JS, Gross CP, Krumholz HM. Promoting transparency in pharmaceutical industry-sponsored research. Am J Public Health. 2012.
    19. Roy H. Perlis, M.D.Clifford S. Perlis, M.D., M.Be.Yelena Wu, B.A.Cindy Hwang, B.A.Megan Joseph, B.A.Andrew A. Nierenberg, M.D. Industry Sponsorship and Financial Conflict of Interest in the Reporting of Clinical Trials in Psychiatry. Am J Psychiatry 162:10, October 2005.
    20. Jonathan Leo, Jeffrey R. Lacasse & Andrea N. Cimino. Why Does Academic Medicine Allow Ghostwriting? A Prescription for Reform. Society volume 48, Article number: 371 (2011) 
    21. From: Academics fronting ghostwritten medical journal articles as ‘guest authors’ should be charged with fraud, say UofT law professors. 2011.
    22. The Guardian. Revealed: how drug firms ‘hoodwink’ medical journals 2003.