Institutional Corruption and Social Justice in Psychiatry

Awais Aftab, MD

Lisa Cosgrove, PhD

CONVERSATIONS IN CRITICAL PSYCHIATRY

Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.

Lisa Cosgrove, PhD, is a Clinical Psychologist and Professor of Counseling and School Psychology at University of Massachusetts Boston, where she teaches courses on psychiatric diagnosis and psychopharmacology. She is a former research fellow at the Edmond J. Safra Center for Ethics at Harvard University. Her research addresses ethical and medical-legal issues that arise in organized psychiatry because of academic-industry relationships. She has published articles and book chapters, has co-edited/co-authored books on these topics, and her research has been cited and discussed in major media outlets. She has received numerous internal and external grants, including federal funding for a study of clinical practice guidelines for depression to determine whether guideline quality is associated with independence from industry. She is the co-author, with Robert Whitaker, of Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform (2015).

In recent years Dr Cosgrove has emerged as a leading expert on how pharmaceutical industry and academic guild interests have shaped the evolution of psychiatry, which she discusses using the framework of institutional corruption. She has been working with the United Nations Special Rapporteur, Lithuanian psychiatrist Dainius PÅ«ras, to develop a framework that emphasizes the right to health and the global burden of obstacles. She criticizes the dominant paradigm in psychiatry and advocates for a social justice and rights-based approach to psychiatry that is thoughtful, measured, and persuasive. A good introduction to her work is the chapter “The Influence of Pharmaceutical Companies and Restoring Integrity to Psychiatric Research and Practice” (co-written with Akansha Vaswani) in the 2019 book Critical Psychiatry: Controversies and Clinical Implications, edited by Sandra Steingard.

Aftab: Your work on institutional corruption in psychiatry is impressive in terms of its scholarly rigor and reliance on empirical evidence, although quite alarming to me as a psychiatrist. I think it will be helpful for the readers if we begin with a brief overview of the concept of “institutional corruption” and what your research work has revealed about the extent of institutional corruption in psychiatry as a profession.

Cosgrove: I was fortunate to have a fellowship at the Safra Center for Ethics at Harvard when Larry Lessig was the director for the lab on institutional corruption. My work over the last decade has been strongly influenced by my time there. As Professor Lessig and philosopher Dennis Thompson note, financial conflicts of interest do not point to wrongdoing per se but rather point to a generic risk that researchers’ corporate ties may compromise the research process or undermine public trust. The framework of institutional corruption helps us see what Lessig calls the “economies of influence” that create an improper dependence for an institution or organization. This dependence results in systematic practices that undermine the integrity of an institution or weaken public trust. These economies of influence-which can include guild interests-take the institution, in this case organized psychiatry, “off course.” The framework of institutional corruption helps us see the systematic practices (eg, commercial ties and guild interests), that draw the institution/organization away from its mission and undermine its integrity.

The difference between institutional corruption and quid pro quo corruption is that the latter is intentional and illegal. In contrast, with institutional corruption the practices causing deviation from the organization’s mission are legal and the actors within the institution typically believe they are acting ethically. Stated simply, the problem is not the bad apple, it is the bad barrel. Most important, this framework is solution, not blame, oriented.

Aftab: Is institutional corruption a problem specific to psychiatry or something that is endemic in medicine in general?

Cosgrove: It is a problem that is endemic in medicine in general. It has been well documented that when clinical practice guidelines are developed primarily or solely by medical specialty groups, they tend to make recommendations that serve the interests of their guild, and when guideline developers have commercial ties, they tend to make recommendations that serve commercial interests, often overestimating efficacy and minimizing harms (of drugs, screening, and interventions). For example, when new guidelines for statin use came out a few years ago it was predicted that more than 13 million more people would be eligible for statins. Investigative journalist Ed Silverman¹ reported in Forbes that of the 15 panelists that authored these new guidelines, six reported having recent or current ties to drug companies that sell or were developing cholesterol medications.

Concerns about implicit bias and undue commercial interests on practice guidelines were one of the reasons that in 2011 the Institute for Medicine (now the National Academy of Medicine) recommended eliminating rather than managing financial conflicts of interest in guideline development groups. When individuals have commercial ties, they are vulnerable to developing subtle, but influential, pro-industry ways of thinking.

Indeed, it is part of the human condition to have implicit biases-and remain blissfully unaware of them. The conditions under which we diagnose a condition, identify evidence-based treatment interventions, and collaboratively try and decide what the best treatment decision is, will always be imperfect.³ However, in an industry-dominated climate, that uncertainty is exacerbated.

So yes, the problem of guild and commercial interests are ones with which all medical specialties must grapple. However, I do think psychiatry is particularly vulnerable to commercial influence because of the lack of biological markers for any of the DSM disorders.

Aftab: What has been your experience with peer review and academic publishing within mainstream psychiatry journals, especially American journals? Since your work is highly critical of the status quo, do you tend to get a lot of push-back from editors and peer reviewers?

Cosgrove: I don’t usually submit a study or paper to an American psychiatric journal for obvious reasons. But do I get a lot of push-back from general medical journals-oh yes! I’ve had rejections that looked like they came straight out of the legal department-even though we never identify individuals. Also, I have to warn students coming into my lab to develop a thick skin when receiving “feedback” from editors and reviewers. But I have found that medical journals that have consciously and explicitly developed policies to better ensure independence from industry have a more robust and fairer peer review process.

Aftab: I think most readers would be aware of the 2016 recommendations from the US Preventive Services Task Force in favor of routine depression screening⁴ for everyone over 13 (including routine screening during pregnancy and the postpartum period) since these recommendations generated a lot of attention when they came out. I must confess, I had no idea until I read your articles^5,6 that available evidence does not support routine depression screening, and that the United Kingdom’s National Screening Committee and the Canadian Task Force on Preventive Health Care, looking at the same evidence, did not recommend routine depression screening. How do we make sense of this discrepancy? How did US Preventive Services Task Force look at the evidence and come to a completely different conclusion?

Cosgrove: That’s a good question and I just want to emphasize that our study was not designed to address the issue of why there is such a discrepancy and so anything I am about to say is purely speculative. I will say that I certainly don’t think it has to do with guild or financial conflicts of interest-the USPSTF has a clear and explicit COI policy and it is a multidisciplinary group. So why did they recommend routine questionnaire-based screening when the available evidence does not support it? I think both the medical profession and lay people want to believe that all screening programs are effective-and in many cases they are. But we need to remember that screening was based on an infectious disease model and there are lots of problems trying to import a questionnaire-based screening model into mental health.

The original impetus for screening programs was to find, prevent, and treat preclinical conditions in asymptomatic individuals in order to stop or delay disease progression. Questionnaire based screening for depression is very different then screening for HIV or Hep-C. And there is a tendency to think “oh but what possible harm could come about from giving people a survey instrument with questions about depression?” We need to heed the wise words of Sir John Muir Gray,⁷ one of the world’s foremost experts on healthcare screening and the former director of the UK National Screening Committee, “All screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost.”

Aftab: Can you share your concerns regarding unintended harms of the routine depression screening?

Cosgrove: Helping people who struggle with depression is a critically important public health issue. But screening for depression, over and above clinical observation, active listening and questioning, will likely lead to over-diagnosis and over-treatment, may unnecessarily create illness identities in some people (ie, the nocebo effect), and exacerbate health disparities by reducing our capacity to care for those with more severe mental health problems- the ones, often from disadvantaged groups-who need the care the most.

Aftab: Another focus of your work is the medicalization of human experiences. I am deeply sympathetic to this line of inquiry and I completely agree that viewing psychological suffering exclusively through the lens of pathology is problematic and harmful. However, at the same time, I struggle with the appropriate response to medicalization. It’s very difficult, if not impossible, to identify instances of “normal suffering” without relying on some arbitrary criteria reflective of human interests. And even if it were possible to identify such instances, there would be cases where medications and/or psychotherapy would be of benefit in offering some relief from suffering.

My view is that in the realm of mental health there is no objective, scientific boundary between the categories of “normal” and “abnormal.” These are constructs based on human interests and human values, so I take issue with both the claim that psychiatric disorders are always the result of a neurobiological dysfunction inside the individual as well as the claim that there is an identifiable realm of normal suffering in which medicine cannot step. What is your approach to this issue?

Cosgrove: I agree with you! We can-and should-challenge the assumption that emotional distress is primarily the result of neurotransmitter dysfunction, and also challenge the idea that “normal suffering”-whatever that is-should not be addressed via psychotropics or psychotherapy. That said, I would still argue that we should be vigilant about the ways in which new conceptualizations of what constitutes a “disease” or “disorder” can inadvertently medicalize normal human conditions and experiences, and lead to over-diagnosis and over/unnecessary treatment. For example, the elimination of the bereavement exclusion, as many clinicians have noted-including Allen Frances the former chair of the DSM-IV-risks medicalizing grief. I think this risk is evidenced in the following statement that was newly included in the DSM-5, “recovery [from bereavement-related depression] may be facilitated by antidepressant treatment.” However, the DSM notwithstanding, there is a growing trend that urges a transition away from medicalization. In fact, leading psychiatrists in the global mental health movement have recently called for a “fundamental re-thinking of psychiatric knowledge creation and training” and emphasized the importance of relational care and of recognizing the interdependence of mental and social health.⁸

Aftab: Can you tell us about your lab at University of Massachusetts Boston? It appears to me to be quite unique in terms of the nature of the research work that is being done as well as the involvement with social activism and the relationship with Mad in America.

Cosgrove: First, in the spirit of full disclosure and with full recognition of my own implicit bias, I need to point out that Bob Whitaker, who started Mad in America (MIA), is my partner. MIA is designed to serve as a resource and community for those interested in rethinking current mental health care systems in the US and abroad. The doctoral students in my lab write summaries of research studies and post them on MIA’s website. The goal is to make research-often only available to those with privilege-accessible to anyone, regardless of socio-economic status, education, or institutional affiliations. Although all citizens deserve full access to scientific information, research findings are often behind paywalls or buried amidst technical jargon. We saw it as a social justice opportunity to provide research summaries of journal articles, sometimes ones that challenge the dominant medical discourse, and for bringing these findings directly to patients, clinicians, and community stakeholders. Also, with a grant from the Open Society Foundation, we have developed a number of podcasts and a (free) webinar on issues related to the Global Mental Health Movement. It amazes me how many downloads and views these summaries and podcasts get-sometimes well over 5000. I think the work that my doctoral students have done has been incredibly valuable in getting research and scholarship out of the ivory tower and into the public where it belongs.

Aftab: You have argued that the question “do antidepressants work?” is reductive and undermines our responsibility to individuals who are suffering from emotional distress.⁹ Can you elaborate on this?

Cosgrove: Questions about the efficacy and effectiveness of antidepressants are usually grounded in a disease-oriented and acontextual symptom reduction model. A symptom reduction model risks individualizing a person’s suffering and moves the focus away from the socio-political context in which “depression” is always manifest. And so I wonder, could such a model inadvertently undermine our ability as clinicians to enter fully and empathically in the other’s world? Are we missing an appreciation for the narrative content of an individual’s experience of because of an over-emphasis on a biomedical model of depression and disease-oriented outcome measures? Emotional suffering has a social, moral, and existential dimension that cannot be easily reduced to a disease category.

Aftab: You advocate for a reconceptualization of psychiatric problems as not truly medical but rather as social and political. However, the fact that social and political factors substantially contribute to a particular condition doesn't by itself imply that the condition is not truly medical. Consider infectious diseases, such as tuberculosis. It is difficult to think of a more clear-cut case of “disease” since there is an identifiable pathogen involved, but it is also the case that vulnerability and exposure to these pathogens and recovery from them in the course of natural history is strongly influenced by social factors such as poverty, living conditions, hygiene, and education. If we didn't know that tuberculosis was caused by a bacterial infection, would you argue that tuberculosis should be reconceptualized as a social and political problem? I have no doubt in my mind that under ideal social-political circumstances the prevalence and severity of depressive symptoms would be dramatically lower, but depression certainly won't disappear. How do you distinguish the role played by social and political factors in cases of established diseases in comparison to cases of syndromic entities such as depression where the interplay of biological, psychological, and social factors is poorly understood?

Cosgrove: The example you give about Tuberculosis is an excellent one, because, as you note, while TB is caused by a specific pathogen, there is a critical socio-political dimension to TB-the countries with the highest rates are typically the poorest and have some of the most unequal societies. I want to emphasize that identifying and addressing the socio-political determinants of mental health should not be conflated with denying the biological bases of behavior or denying the helpfulness of psychotropic medication. Therefore, rather than try to precisely determine the roles played by social or biological factors in depression or other mental health conditions, I believe that our energies would be better spent in trying to develop and extend human rights approaches.

This point was beautifully summed up by child psychiatrist Dainius Puras, the United Nations Special Rapporteur as the right of everyone to enjoy the highest attainable standard of physical and mental health. Dr Puras has emphasized that we must shift the rhetoric and engage in policy development to address the global burden of obstacles (e., violence, discrimination, poverty), rather than focus mainly on the global burden of mental disorders. The Special Rapporteur has worked tirelessly on incorporating a rights-based, social justice approach to mental health issues. I serve as a consultant to Dr Puras and two doctoral students in my lab, Justin Karter and Zenobia Morrill, are Research Officers for him. We have had the pleasure and privilege of working with him and his advisor, Julie Hannah, on some of the thematic reports (see eg, The Role of the Determinants of Health in Advancing the Right to Mental Health, A Human Rights-Based Approach to Health Workforce Education) that the Special Rapporteur submitted to the UN.

Indeed, when mental health problems are seen as predominantly medical and when the social, political, or existential dimensions are glossed over, responses tend to be centered around individual-level interventions. Such interventions aim to return an individual to functioning within a social system, rather than addressing change at the social level. Interestingly, “housing first” programs have been linked to lower rates of inpatient hospitalization, while studies that have investigated the effects of addressing mental health needs before offering housing have not shown promising outcomes. Similarly, poverty reduction programs have been found to decrease depressive symptoms. Psychologists and psychiatrists might be surprised by that research, and these findings may challenge our guild interests, but we have an ethical and intellectual responsibility to incorporate that research into the development of clinical care guidelines and mental health policies.

Aftab: What can individual psychiatrists, such as me, do in this climate of “institutional corruption” to enact change in the profession?

Cosgrove: Thank you for asking that question and you’re doing it! Enacting change means (1) being willing to look at empirical evidence that may challenge our most cherished beliefs; (2) working to include genuine stakeholder involvement-that is, the voices, opinions, and scholarship of those individuals who have been diagnosed with mental disorders-into clinical care guidelines and mental health policies; and (3) making independence from Big Pharma a sign of prestige within psychiatry. For example, I will audaciously suggest that the editors of psychiatry journals could be on the cutting edge and refuse to have industry ties if they wish to serve as an editor or on editorial boards. And, of course, we must all work toward incorporating a human rights-based approach that addresses the social determinants of health into our research and practice. In this regard, I’m heartened by the Structural Competency framework put forth by Jonathan Metzel and Helena Hansen.¹⁰

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

Dr Aftab is a psychiatrist in Cleveland, OH. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab.

Dr Aftab and Dr Cosgrove have no relevant financial disclosures or conflicts of interest.

An earlier version of the interview used the term "bereavement" when referring to the DSM statement "recovery may be facilitated by antidepressant treatment.” This was changed to "bereavement-related depression" to clarify that the DSM makes a distinction between bereavement and major depression in the context of bereavement. We thank Dr Ronald Pies for his input with regard to this clarification. -Ed.

Previously in Conversations in Critical Psychiatry

Relentless Warrior for Mental Health: Allen Frances, MD

The Structure of Psychiatric Revolutions: Anne Harrington, DPhil

Skepticism of the Gentle Variety: Derek Bolton, PhD

Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD

Chaos Theory with a Human Face: Dr Niall McLaren

The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH

Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD, and G. Scott Waterman, MD

Social Constructionism Meets Aging and Dementia: Peter Whitehouse, MD, PhD

50 Shades of Misdiagnosis: Susannah Cahalan

References:

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2. Institute of Medicine (U.S.) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Graham R. Clinical Practice Guidelines We Can Trust. Washington, D.: National Academies Press; 2011.

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