Seite 3: Conflicts of Interest

To what extent do financial conflicts of interest play a role?

Michael P. Hengartner: They are a very big problem. We now know that the key opinion leaders in psychiatry heavily depend on the money of the pharmaceutical industry. Some of them have financial ties with six to eight different companies.

In some cases it has been documented that someone could earn hundreds of thousands of dollars within a couple of years with giving talks, working as an advisor, or in other functions. Some even are shareholders of the companies, whose products they are supposed to investigate neutrally and independently. Such people and their employees then produce the results which are required by the regulatory agencies for market approval.

In addition to that, the pharmaceutical industry funds the majority of the trials. Also conferences and education are supported financially and stuffed with pro-drug content. How should a neutral, critical opinion, as we expect it of science, be still possible under such conditions?

One anecdote to illustrate the problem: Marcia Angell, former editor-in-chief of the New England Journal of Medicine, one of the leading medical journals, once was looking for a well-known psychiatrist without a conflict of interest. He or she should write an editorial for a particular research topic. However, it was virtually impossible to find someone like that among the leaders of the field.

But there are also patients who are convinced that the drugs helped them. How do you explain such cases?

Michael P. Hengartner: As I said, antidepressant drugs are psychoactive substances, which have mental and physiological effects. SSRIs, for example, have activating effects in some people. Those patients suffering from lethargy can experience that as very helpful.

In others this activation can lead to agitation, manic thoughts and sleeplessness. I do not doubt that antidepressant drugs have effects, but just that they are specifically anti-depressant. And I also think that their effects can cause harm in the long term.

Besides that, for some patients the belief that one is getting treatment is helpful. It is frequently neglected that people get attention in addition to the drugs, which is also a medical service. Somebody is assessing one’s symptoms, asking how they feel.

This alone can already improve the symptoms. Probably many patients, had they received a placebo instead of an antidepressant drug, would have had very similar experiences. In clinical practice, though, this is not feasible for ethical reasons.

Alternatives

And finally: Your summary of the research draws a rather disconcerting image of psychiatry and psychopharmacology. Do you have an idea what a better alternative could look like?

Michael P. Hengartner: Personally I think that the pharmaceutical industry should no longer be allowed to determine the effectivity of their own drugs. Imagine that a football team would be allowed to appoint its own referee! Everybody immediately understands that sports would not work like that.

Why is it then different in science? There has to be a completely independent agency carrying out the study from beginning to end, including the publication. This means that the dependency on the pharmaceutical industry, which has unfortunately reached a catastrophic dimension, has to be reduced.

The conflicts of interest already arise where experts think about the definition and diagnosis of mental disorders. As a result, grief and strain due to stressing life events have been turned into a mental disorder in some cases, which are then treated psychopharmacologically. Also, the treatment guidelines should not be written by experts who are earning thousands or perhaps even hundreds of thousands of dollars with their additional business for the pharmaceutical industry.

This is still argued from the experts' perspective. Is there something you can recommend with respect to patients?

Michael P. Hengartner: It is important to raise awareness for these issues among doctors and patients. There are alternatives to medical treatment particularly for mild forms of depression. In addition to that, more than half of antidepressant drugs are prescribed to people who don’t even have a diagnosis of depression.

For such people without a diagnosis and for those with mild forms of the disorder, one should rather consider social or psychological interventions. One should certainly not understand the drugs as "happy pills." It is concerning that nowadays in the USA about 20 percent of women aged 40 to 60 receive prescriptions for antidepressant drugs!

Many such people are simply overstrained, frustrated, or stressed out. Then one should consider the circumstances in one’s life, sleep hygiene, and diet. We also know that outdoor activities and exercise can help many people. That should be the first-line treatment in milder cases.

And even in severe cases of depression psychotherapy has been proven an effective alternative to medication. Psychotherapy seems to be superior to psychopharmacological treatment particularly in the long term, as it can also help people to find a job, for example. That is something the drugs cannot do. Another advantage of psychotherapy over pharmacotherapy is that it cannot cause severe somatic disorders.