Vol 6 #5

Alan Eppel MB, FRCPC

In this edition of JPR we have reprinted an article written by Lisa Cosgrove from the Edmond J. Safra Center for Ethics at Harvard and Sheldon Krimsky from Department of Public Health and Community Medicine, Tufts University. The article written in 2012 addresses some hidden aspects of conflicts of interest. The authors identify undeclared are nontransparent conflicts of interest of DSM panel members (1) .

The International Committee of Medical Journal Editors [ICMJE] has established principles and requirements for disclosure of conflicts in all phases of the publication process (2). Authors, peer reviewers, editors and journal staff are required to disclose conflicts of interest. The role of funding sources in data collection, analysis, interpretation; trial design; patient recruitment and write up of the study must be disclosed.


“A conflict of interest exists when professional judgment concerning a primary interest (such as patients’ welfare or the validity of research) may be influenced by a secondary interest (such as financial gain)………….”

“…the credibility of published articles depend in part on how transparently conflicts of interest are handled during the planning, implementation, writing, peer review, editing, and publication of scientific work” (2).

Doucet and  Sismondo (3) describe that pharmaceutical sponsorship may include the design of a trial that is carried out by a private contract company and  written up by paid “ghostwritters”. These trials may contain design bias affecting the choice of comparators, drug dosages, length of study  and concealment of data.

COI is most obvious in the case of physician relationships with pharmaceutical companies. These relationships include payment for presentations, assistance with publication, sponsorship of drug studies, payments for recruitment of patients, payment of travel and conference expenses, financial support for the development of treatment guidelines, employment by a company and stock holdings.

While physicians and other scientists may have been educated and are now aware of the potential influence of conflicts of interest in the publication world, they may be less aware that conflicts can insidiously affect the development of treatment guidelines and even more so the determination of diagnostic criteria. Changes to diagnostic criteria or guidelines can have an enormous impact on the marketing of medications. Clearly medications that are designated as first-line in guidelines can be predicted to lead to an increase in sales.

Alteration of diagnostic definitions to increase indications for specific drugs can have huge marketing implications which are hidden from the view of most clinicians. For example the change in the age criteria in DSM for the diagnosis of Attention Deficit Hyperactivity Disorder greatly enlarged the potential market for these medications.



COI is a major threat to psychiatry and has resulted in vigorous critiques of psychiatric practice and ethics. It has eroded confidence in psychiatric treatment and research.

Disclosure does not remove the biasing effect of COIs. A list of affiliations to drug companies does not “undo” the potential impacts on research findings.

A more robust system is required to allow readers to make their own assessment of credibility of journal publications, guidelines and diagnostic categories. More detailed information about authors and panelists must be provided, identifying specifically how a COI might impact the abstract, design, methods, conclusions, guidelines and diagnostic categories.



  1. Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190.
  2. International Committee of Medical Journal Editors
  3. Doucet M, Sismondo S. Evaluating solutions to sponsorship bias. J Med Ethics 2008;34:627–630. doi:10.1136/jme.2007.022467


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