APA Assembly Rejects Proposed Conflict of Interest Recommendations

Caroline Cassels

June 11, 2010

June 11, 2010 (New Orleans, Louisiana) — The American Psychiatric Association (APA) Assembly has rejected an internal report containing a set of 14 proposed recommendations designed to regulate and significantly curtail individual psychiatrists' relationships with the pharmaceutical industry.

The draft report, developed by an 11-member APA work group headed by APA Past-President Paul Appelbaum, MD, was first released a year ago and distributed to APA members for feedback.

"Ironically, it appears to be very difficult for many psychiatrists to accept the notion that there may be influences on their behavior that are outside of their conscious perception." — APA Past-President Paul Appelbaum, MD

Its release followed a media spotlight on alleged undeclared conflicts of interest between several high-profile physicians and the pharmaceutical industry. It was slated for discussion at the recent meeting of the national APA Assembly, held May 21 to 23, but was reportedly quashed before reaching the assembly floor for debate.

"The reference committee strongly recommended the report be rejected and refused to allow it to come to the floor for discussion — this, despite considerable efforts from some of the younger psychiatrists to introduce it. So, as [Larry Martin, MD, the chair of the reference committee,] said, 'This report is dead as far as the assembly is concerned,' " Dr. Appelbaum told Medscape Psychiatry.

Dr. Paul Appelbaum

However, far from being a dead issue, other APA Assembly members, most notably Joshua Sonkiss, MD, who, according to Dr. Appelbaum, led the push to have the report debated at the assembly meeting, believe it is only a matter of time before the APA adopts such recommendations.

"As the opposition ages out of the organization and as younger psychiatrists who grew up in a different ethical environment and have different professional values that are more reflective of those of mainstream medicine, age into the organization, these guidelines will inevitably be adopted by the APA. It may not happen at the next assembly meeting [in November], but I have every expectation that it will eventually happen," Dr. Sonkiss said in an interview.

External Regulation

Although this may be true, said Dr. Appelbaum, by not adopting the guidelines in an expeditious manner, the APA is running a serious risk for external regulation.

"I would rather we regulate ourselves than have it imposed on us from outside. But at this point I am not optimistic about our ability to do that," said Dr. Appelbaum.

To some extent, he added, there already is external regulation, noting that the Physician Payment Sunshine Provisions in the new healthcare reform law will require pharmaceutical and device manufacturers to disclose payments to physicians and some hospitals, starting in 2012. In addition, he said, some states, most notably Massachusetts, have adopted stringent legislation that sets limits on the size of gifts and other benefits physicians receive from industry.

The Appelbaum report's proposed recommendations address issues such as gifts from the pharmaceutical industry, receipt of medical samples, attendance at industry-sponsored events, consulting for industry, contact with pharmaceutical representatives, and disclosure of relationships with pharmaceutical companies.

APA President Carol Bernstein, MD, said the rejection of the Appelbaum report by the reference committee, which acts in an advisory capacity to the organization's board of trustees, should not be interpreted as a rejection of the report by the APA.

Dr. Carol Bernstein

"It would be absolutely unfair and untrue to say that as an organization the APA is against conflict-of-interest guidelines to help guide members' relationships with industry," Dr. Bernstein told Medscape Psychiatry. She added that under her leadership, the conflict-of-interest issue will be front and center.

Specifically, she said, the Appelbaum report and the overall issue of conflict of interest will be on the agenda at the APA's next board of trustees meeting in September.

Generational Divide

According to Dr. Appelbaum and Dr. Sonkiss, the opposition to the report broke down roughly along generational lines, with younger assembly members — members in training and early career psychiatrists — generally in support of the report, and veteran clinicians generally against it.

Although there there's no doubt that conflict-of-interest guidelines are a controversial and divisive issue within the APA, psychiatrists need to recognize that their association is lagging behind other medical organizations when it comes to addressing the issue, said Dr. Sonkiss.

"Unfortunately, there's clearly a large faction [within the APA Assembly] that doesn't want any specific guidelines, and that faction has objected [to the report] on the basis that they feel the tone is condescending, and the content too restrictive and too directive.

"This is notwithstanding the fact that these [proposed] guidelines are very, very similar to guidelines that have already been adopted by mainstream medicine including the Association of American Medical Colleges, the American Medical Association, and the Institute of Medicine, as well as most academic institutions around the country," said Dr. Sonkiss.

Widespread Denial

Dr. Appelbaum said there appears to be "widespread denial" among many psychiatrists that involvement with industry influences their behavior, "[d]espite the fact that there is a substantial body of research demonstrating the reason pharmaceutical companies sponsor talks, give out gifts, and send marketing representatives around is because all of these actions do, in fact, affect physician prescribing.

"Ironically, it appears to be very difficult for many psychiatrists to accept the notion that there may be influences on their behavior that are outside of their conscious perception," said Dr. Appelbaum.

After the assembly meeting, Dr. Appelbaum said he was approached by several psychiatrists who told him they would have liked to support the recommendations but for the fact that many of them have substantial financial ties to industry, which include paid speaking engagements.

"As one assembly member put it to me, 'I give those talks, and they pay my mortgage, so I just can't stop doing that.' So ironically, there were substantial conflicts of interest among the very people who were voting on a set of recommendations intended to regulate conflicts of interest," said Dr. Appelbaum.

Dr. Appelbaum said that although he could not vouch for the figure, one member said that two thirds of APA assembly members give paid talks for industry.

Right Thing to Do

Dr. Sonkiss said he and other members of the assembly who support the report will be working with Dr. Appelbaum and members of his working group to reintroduce the report at the next assembly meeting, which will be held from November 19 to 21.

Dr. Joshua Sonkiss

"There may be some minor changes to the text to make it more acceptable to those who object, but I have every reason to believe that the bulk of the Appelbaum report — the most important parts of it, if not all of it — will be reintroduced at the November assembly meeting in the form of an action paper that can be moved from the floor and will be debated," said Dr. Sonkiss.

He added that concerns have been expressed that if the guidelines pass, it could cause many members to terminate their APA membership. However, he said, not adopting the guidelines could be equally divisive and cause many young psychiatrists to reconsider their membership if they feel their professional values are not reflected by the organization.

Historically, said Dr. Sonkiss, progress is not gained without struggle. "Almost every major historical landmark of progress — the abolition of slavery, child labor reform, women's suffrage, civil rights — has been divisive, but each was accomplished because it was the right thing to do. Whether it is divisive or not, passing the Appelbaum report is also the right thing to do."

Medscape Psychiatry attempted to contact Larry Martin, MD, reference committee chair, through the APA press office. However, he was away and unavailable for comment at the time of publication.