The accompanying editorial from Dr. Kevin Hill, written as he finished his residency, is an articulate statement of an ever-growing conflict of interest that every physician must address in recommending treatment to a patient. His problem with a drug company pen is replicated and enhanced many fold in publishing The American Journal of Psychiatry.
Surveys of physicians find that over 90% of us look to original articles in medical journals as our most preferred source of new information for help in treating patients. That responsibility requires that journals seek 1) authors whose studies yield the most useful new information, 2) reviewers who can probe the veracity of these new findings, 3) editors who can select the best articles for readers, and 4) editorial commentators who can highlight the implications for clinical practice. The object of our conflict of interest policy is to assure our readers that each author, editor, reviewer, and commentator acts only to provide the best information for clinical practice. The task is a daunting one and, for The American Journal of Psychiatry, one that involves over 2,500 submitted articles per year (of which about 250 will be selected for publication), 20 deputy and associate editors, and over 5,000 reviewers. The editors of the Journal are entrusted with the responsibility of formulating and enforcing this policy.
The management of conflict of interest begins with disclosure. Authors are required to inform the Journal about who supported their work and whether they have other financial interests that could potentially affect their article. The Journal publishes work supported by a variety of sources, usually government grants, nonprofit foundations, and pharmaceutical companies. Attention is currently focused on pharmaceutical companies because of well-publicized problems in the complete reporting of data, including the risk of suicide with antidepressant drugs. However, there are also examples of misreporting that do not involve pharmaceutical companies. In cooperation with other international medical journals, we are continually increasing our reporting of the financial interests of our authors. We have adopted the policy of requiring public reporting of the scope of clinical trials at the initiation of study, using vehicles such as www.clinicaltrials.gov, to prevent incomplete and therefore misleading reporting of a study’s results. We require that all authors have complete access to data and that all authors, including industry employees, be identified.
A second safeguard against inaccurate reporting due to conflict of interest is the review process. Editors and reviewers are experts responsible for determining whether articles are accurate reports of the studies. Their role inevitably brings up the issue of their own conflicts of interest. As Editor and Deputy Editors we have this primary responsibility, and report all our financial conflicts in the first issue of each year. We do not work with manuscripts with which we have a conflict. Similarly, reviewers and Associate Editors are asked to disclose any conflict with a manuscript they have been asked to review. The Editor is responsible for determining when such conflicts preclude participation in the editorial and review process. Manuscripts submitted by the Editor and Deputy Editors of The American Journal of Psychiatry represent a special conflict of interest. These manuscripts are handled independently by a special Associate Editor of this journal: Howard Goldman, who is Editor of Psychiatric Services.
Many journals believe that commentaries—review articles, clinical practice articles, and editorials—require special disclosure. For these articles, we ask authors to advise readers about treatment and other clinical issues. We have not set a policy that prohibits authors of commentaries from having such conflicts. Work with the pharmaceutical industry is a useful part of the activity of many clinical investigators. It enables them to interact with scientists in industry, who themselves have considerable expertise in treatment and treatment evaluation, and it enlists our best minds in the development of new therapeutics for our patients. As commentators, these individuals then bring broad experience to their role of advisers to readers. However, our readers need to know of authors’ conflicts, and we need to assure readers that articles are not influenced by conflicting interests. Therefore, we will include with commentary articles a disclosure of the authors’ relevant interests with a notation that an editor has reviewed the article to discern and exclude bias in its conclusions or its clinical recommendations.
There are two interactions in which one needs to be as free from conflicts of interest as possible: in the treatment of a patient, which is why Dr. Hill’s editorial is relevant, and in representing our field to the public. The Journal speaks directly to the public as well as to physicians about the practice of psychiatry. Therefore, the Editorial Board of the Journal and the APA Editor Search Committee required that the new Editor-in-Chief of The American Journal of Psychiatry, as its lead spokesperson, have no commercial conflicts of interest. Dr. Freedman has agreed to this requirement.
The Journal is supported primarily by our readers’ subscriptions. Our readers can be proud of having an independent journal that they support themselves as a primary source of information about their field. However, the Journal also accepts advertising as a secondary source of income. Obviously, most of the advertising is from pharmaceutical companies, which introduces another potential conflict of interest. Some of the pages of our journal are not dissimilar to Dr. Hill’s pen. How do we address this conflict of interest? First, should we accept industry advertising at all? There is no facile solution. The pharmaceutical industry is the ultimate source of most neurobiologically based psychiatric treatments, and it is the most financially successful element in the process. Therefore, it would seem self-defeating to try to ignore its presence and to eschew its support. However, the advertisements are quintessential marketing efforts, incongruously juxtaposed to our more somber articles. The cost of these advertisements is borne not by us, but by our patients.
At the present time we have a policy that restricts but does not preclude such advertising. We do not allow advertising to be facing or interleaved with articles, to prevent an advertisement for a product from appearing with an article about its use. We do not allow advertising that purports to contain educational content, such as industry-sponsored CME articles, to be part of the Journal or to be comailed to our readership. We receive repeated requests for both these features, which are highly desired by advertisers. (It should be noted, however, that article reprints—frequently purchased by industry and distributed in combination with promotional material—are a significant source of income for the Journal.)
A conflict of interest should not be mislabeled as a lack of personal integrity. There are many roles in the development and delivery of treatment to our patients. We cannot treat many of our patients without the help of the medicinal products of the pharmaceutical industry, but the industry itself cannot advocate the value of its products without the voice of independent physicians and medical journals. All of these roles involve an interaction of personal and financial interests. Conflict of interest policies do not eliminate these interactions; they simply make each person’s role apparent to everyone else. Standards are constantly changing and public perception of our independence is critical. Many industry leaders have similar beliefs. Our tolerance of overzealous marketing diminishes everyone’s credibility. Our ability to maintain our integrity as physicians and the independence of our publications is therefore critical to assure our patients of the best possible treatment now and in the future.