Anatomy of an Organization: an Ethnographic Approach to Understanding the History and Ethics of the American Psychiatric Association

Although all medical specialties have come under scrutiny for financial conflicts of interest, the field of psychiatry has been at the epicenter of this "crisis of credibility" (Fava, 2006). Researchers, investigative journalists, and policy makers have raised questions about the extent of industry influence on the diagnostic and practice guidelines developed by the American Psychiatric Association (APA). In 2008, Senator Charles Grassley sent a letter to the APA expressing concerns about the APA's financial relationship with pharmaceutical companies and, concomitantly, undue industry influence. Clearly, much is at stake in terms of profits, institutional reputation, and trust; the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM) is often referred to as the bible of psychiatric disorders because of its enormous influence on clinical practice, affecting such disparate domains as jurisprudence and insurance claims. The APA also produces and disseminates clinical practice guidelines directly tied to DSM diagnoses. The publication of the DSM-V, scheduled for 2013, will not only generate millions in additional revenue for the APA but, along with the practice guidelines, will also affect what health practitioners prescribe to patients. Lisa Cosgrove's work addresses the problems and ethical dilemmas that arise in psychiatry when there are financial ties between the pharmaceutical industry and researchers or professional organizations. Cosgrove and her colleagues (e.g., Harold Bursztajn, Allen Shaughnessy and Sheldon Krimsky) have conducted studies examining the type and extent of financial associations between authors of psychiatric diagnostic and treatment guidelines the pharmaceutical industry. Arguing that transparency is an insufficient solution, she and her colleagues have offered policy-based recommendations based on their empirical work. Cosgrove has published over 30 peer-reviewed journal articles and book chapters and her research on conflict of interest has been discussed in both academic journals and by the media (e.g., The New York Times, the Washington Post, USA Today, U.S News and World Report, the New Scientist, the Boston Globe, and NPR, BBC, and Fox News).

During the Fellowship year 2011-2012, Robert Whitaker and Lisa Cosgrove will produce a monograph on the APA. Robert Whitaker is an award winning investigative journalist who has written extensively about institutional corruption within organized psychiatry. He has written four books, including Mad in America and most recently (2010) Anatomy of an Epidemic. The monograph that will be produced will discuss in detail threats (real and perceived) to APA's independence and trustworthiness as an institution. Possible solutions to these threats will be identified and discussed in terms of their feasibility. Also, and in keeping with the Lab's focus on building "tools" (based on the empirical work of the Lab), another segment of this project will include the development of an empirically-based consumer guide for people considering taking antidepressant medication. Cosgrove and colleagues are currently working on a critical appraisal and quality assessment of APA's practice guidelines on depression and this guide will allow them to disseminate their study results in a format that is accessible to the general public.

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