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Conflict resolution
Editorial
Why spend your life in medical research? Ask anyone, and the answers will be similar: to cure disease, to improve lives, to further knowledge. Yet we are all fallible human beings: researchers dream of fame and accolades, pharmaceutical companies of riches, and publishers of impact factors and commercial reprints. The ethical concept of declaring competing interests— acknowledging the potential corruption of scientific neutrality by personal gain—attempts to bridge the gap between scientific integrity and commercial reality through transparent reporting. It’s not just about the money. In mental health, reputational interests exist alongside potential financial conflicts. There might also be deep-rooted interests based on professional identity. Our specialty sometimes resembles a field of conflict, or maybe some particularly ill-tempered football league—psychiatrists versus psychiatrists, psychiatrists versus psychologists, behavioural psychologists versus psychoanalysts, pill pushers versus therapists, and, as a forthcoming attraction, ICD versus DSM—a world of factionalism, rifts, ideology, personal philosophy, and ego (or should that be id?). There are also hot-button research topics that sometimes seem to divide the field between—to paraphrase returning TV sci-fi show The X-Files—those who want to believe, and those who trust no-one. In other words, if we agree that professional judgment can be compromised by secondary interests, then to define competing interests as exclusively financial and Big Pharma-led is to have too narrow a focus. Although pharmaceutical companies have a significant (and not necessarily benign) role in psychiatry research, pharmacological therapy is arguably less important than in other specialties, and certainly not the be-all and end-all. Journal editors already pay attention to what grants, shares, and honoraria researchers have collected. We should, perhaps, give more consideration to the potential benefits the authors of a paper might reap from championing a particular rating scale, set of diagnostic criteria, training course, psychotherapeutic approach, or book, and whether it might affect the science being reported. Some journals, including The Lancet Psychiatry, have a “publish and declare” policy on competing interests, making every effort to ensure that authors’ financial conflicts are clearly stated, allowing readers to make www.thelancet.com/psychiatry Vol 2 July 2015
up their own minds. Other journals pursue a very strict and vigorously enforced approach, for example refusing to publish non-research articles on depression from authors who have received unrelated funding from pharmaceutical companies that market any antidepressants. How conflicts of interest are defined and declared continues to be hotly debated. Writing in The New England Journal of Medicine, Lisa Rosenbaum recently pleaded that good research should not be disregarded by “pharmascolds” because of who paid for it, no matter how vested the interest; her former colleagues subsequently took to The BMJ to defend the principle of keeping financial conflicts out of medicine. The approach advocated in the NEJM seems too laissez faire to us, and the word “pharmascolds” an unnecessary neologism that makes its second and final Lancet Psychiatry appearance in this sentence. But that leaves us, indeed all editors, with difficult decisions, particularly in mental health. Is the researcher who communicates his or her work to the general public an advocate for mental health science, or a salesperson? Is the voice loudly and repeatedly criticising a particular branch of practice—psychological or pharmacological—expressing a strong, necessary, and deeply held opinion, or pursuing a professional vendetta? Editors, of course, do not come from a neutral position: we have our own views on the direction of mental health research and care, and are prone to the flattery of having our prejudices confirmed. Although we strive consciously to resist, our office copy of Sigmund Freud’s Psychopathology of Everyday Life provides a constant reminder of the power of unconscious drives. Proper declaration and consideration of conflicts of interest are essential, but the process does not end with a competing interests statement. Journal editors must ensure that, above all, research (whatever its source or clinical approach) is not wasted and answers questions that will help find better treatments for patients rather than simply providing marketing opportunities. This requires active engagement across stakeholders, including other journals, researchers, and funding bodies. We should continue to question, query, probe, and interrogate, even—and especially—if it makes us uncomfortable. At the very least we can aim to be, as Raymond Chandler wrote of his world-weary detective Philip Marlowe, “puzzled but never quite defeated”. ■ The Lancet Psychiatry
Pelican Books
Conflict resolution
See N Engl J Med 2015; 372: 1959–63 See BMJ 2015; 350: h2942 For more on efforts to reduce research waste see Lancet 2015; 385: 2121
571
Why spend your life in medical research? Ask anyone, and the answers will be similar: to cure disease, to improve lives, to further knowledge. Yet we are all fallible human beings: researchers dream of fame and accolades, pharmaceutical companies of riches, and publishers of impact factors and commercial reprints. The ethical concept of declaring competing interests— acknowledging the potential corruption of scientific neutrality by personal gain—attempts to bridge the gap between scientific integrity and commercial reality through transparent reporting. It’s not just about the money. In mental health, reputational interests exist alongside potential financial conflicts. There might also be deep-rooted interests based on professional identity. Our specialty sometimes resembles a field of conflict, or maybe some particularly ill-tempered football league—psychiatrists versus psychiatrists, psychiatrists versus psychologists, behavioural psychologists versus psychoanalysts, pill pushers versus therapists, and, as a forthcoming attraction, ICD versus DSM—a world of factionalism, rifts, ideology, personal philosophy, and ego (or should that be id?). There are also hot-button research topics that sometimes seem to divide the field between—to paraphrase returning TV sci-fi show The X-Files—those who want to believe, and those who trust no-one. In other words, if we agree that professional judgment can be compromised by secondary interests, then to define competing interests as exclusively financial and Big Pharma-led is to have too narrow a focus. Although pharmaceutical companies have a significant (and not necessarily benign) role in psychiatry research, pharmacological therapy is arguably less important than in other specialties, and certainly not the be-all and end-all. Journal editors already pay attention to what grants, shares, and honoraria researchers have collected. We should, perhaps, give more consideration to the potential benefits the authors of a paper might reap from championing a particular rating scale, set of diagnostic criteria, training course, psychotherapeutic approach, or book, and whether it might affect the science being reported. Some journals, including The Lancet Psychiatry, have a “publish and declare” policy on competing interests, making every effort to ensure that authors’ financial conflicts are clearly stated, allowing readers to make www.thelancet.com/psychiatry Vol 2 July 2015
up their own minds. Other journals pursue a very strict and vigorously enforced approach, for example refusing to publish non-research articles on depression from authors who have received unrelated funding from pharmaceutical companies that market any antidepressants. How conflicts of interest are defined and declared continues to be hotly debated. Writing in The New England Journal of Medicine, Lisa Rosenbaum recently pleaded that good research should not be disregarded by “pharmascolds” because of who paid for it, no matter how vested the interest; her former colleagues subsequently took to The BMJ to defend the principle of keeping financial conflicts out of medicine. The approach advocated in the NEJM seems too laissez faire to us, and the word “pharmascolds” an unnecessary neologism that makes its second and final Lancet Psychiatry appearance in this sentence. But that leaves us, indeed all editors, with difficult decisions, particularly in mental health. Is the researcher who communicates his or her work to the general public an advocate for mental health science, or a salesperson? Is the voice loudly and repeatedly criticising a particular branch of practice—psychological or pharmacological—expressing a strong, necessary, and deeply held opinion, or pursuing a professional vendetta? Editors, of course, do not come from a neutral position: we have our own views on the direction of mental health research and care, and are prone to the flattery of having our prejudices confirmed. Although we strive consciously to resist, our office copy of Sigmund Freud’s Psychopathology of Everyday Life provides a constant reminder of the power of unconscious drives. Proper declaration and consideration of conflicts of interest are essential, but the process does not end with a competing interests statement. Journal editors must ensure that, above all, research (whatever its source or clinical approach) is not wasted and answers questions that will help find better treatments for patients rather than simply providing marketing opportunities. This requires active engagement across stakeholders, including other journals, researchers, and funding bodies. We should continue to question, query, probe, and interrogate, even—and especially—if it makes us uncomfortable. At the very least we can aim to be, as Raymond Chandler wrote of his world-weary detective Philip Marlowe, “puzzled but never quite defeated”. ■ The Lancet Psychiatry
Pelican Books
Conflict resolution
See N Engl J Med 2015; 372: 1959–63 See BMJ 2015; 350: h2942 For more on efforts to reduce research waste see Lancet 2015; 385: 2121
571