Narrowing the 'Credibility Gap'

Letter to the Editor by Stefan P Kruszewski, M.D.
Psychiatric News October 21, 2005
Volume 40 Number 20 Page 29

 In his July 1 "From the President" column, APA President Steven Sharfstein, M.D., addressed some of the economic issues that plague psychiatry, such as losing ground in reimbursements with a decrease in expenditures, as a percentage of total health care dollars, from 8.2 percent in 1991 to 7.6 percent in 2001. The problems that plagued psychiatric reimbursement 20 years ago have grown worse. As Dr. Sharfstein noted, the cost shift to states' fee-for-service and managed Medicaid programs have become primary payers—and poor ones at that. With imminent cutbacks amid Medicaid financial shortfalls, that payer system continues to implode.

 Dr. Sharfstein's responses to this dismal outlook are APA's Business Relations Initiative and federal and state legislative lobbying efforts and advocacy to increase access as "more and more individuals realize that treatment works and seek to obtain it."

 Those initiatives haven't had much success in the past. And repeating those same initiatives is not likely to produce broadly better results in the future.

 It is my opinion that psychiatry has a credibility gap and that credibility gap is widening as the disclosure of public psychopharmaceutical embarrassments continue to destroy its image. Why should this be the case? Why should one of the most fundamentally important medical specialties—one that seeks to address the medical, emotional, cognitive, and spiritual components of a human being—lose its luster vis-à-vis other medical specialties as it loses its competitiveness for the health care dollar?

 I don't pretend to have a comprehensive answer to that question. But I offer this suggestion: psychiatry must address its internal issues before it seeks to blame others for its failures.

 What are the issues that compromise its integrity, attractiveness, competitiveness and credibility?

Research integrity: As a specialty, psychiatry should not expect to enhance its reputation until its research byproducts are grounded in robust scientific methodology and anonymous peer-reviewed journalism.

Conflicts of interest: APA cannot continue to bankroll its operations and research efforts with monies from pharmaceutical companies and expect the public to respect either its advertising hyperbole or research results.

 A fundamental problem for APA's governing bodies is denial. It is not unlike the denial pervasive in drug and alcohol addictions or any other problem when a person, group, or organization either refuses or—for whatever reason—cannot deal realistically with issues that confront it. APA and its governing bodies need to look within themselves—with the capacity for honest and revealing gut-wrenching, insight-oriented organizational analysis. Until APA is able to shake loose the chains that bind it to the pervasive influences of pharmaceutical and technical-gadgetry corporations (whose hefty price tags include an assault on the credibility of every research and clinical psychiatrist), the golden age of psychiatry will be only a glimpse of what has been, since the seeds of psychiatry's future failures will have been nurtured by psychiatry's current inability to address the prostitution of its core values and worth.

Dr. Sharfstein responds:

 Dr. Kruszewski comments on the "credibility gap" that psychiatry faces today in the political and economic marketplace. He echoes comments I made in my president-elect speech in Atlanta last May when I stated that "our profession lacks credibility and leverage" and that we are experiencing "a crisis of credibility for American medicine and American psychiatry." In particular, I expressed my concern about both the perception and reality of conflict of interest in our relationships with the pharmaceutical industry.

 I believe a fundamental distinction must be made between APA as a professional organization and individual psychiatrists who treat patients. APA does not treat patients, and the vast majority of its support from the pharmaceutical industry is derived from the advertising in our journals and newspaper and industry-sponsored symposia at our annual meetings. All of these activities are scrutinized in great detail by various APA components for accuracy and truthfulness and for the image they portray of the profession.

 We should do more, however, as this is an ever-changing environment. APA needs to do more related to individual psychiatrists who often find themselves" corrupted in the marketplace with lucrative consulting to industry, speaker panels, boards of directors, and visits from industry representatives bearing gifts."

 In contrast to APA as an organization, these psychiatrists see patients, write prescriptions, and recommend various medication strategies. Our patients must feel that their needs are first and foremost. What must take place, I believe, is much more than an "organizational analysis" that Dr. Kruszewski suggests. As a profession, we must do much more to earn back our moral authority. We must evaluate all arrangements that psychiatrists have with industry and provide guidance and standards. We must speak up for access to all clinically important information that pharmaceutical companies possess so that we can treat our patients ethically and with quality.

 I appreciate Dr. Kruszewski's candid assessment of our governing body, and I would like to assure him and others that we are most concerned about the issues he raises.