Thomas A. Ban’s final reply to Ernst Franzek’s
and Edward Shorter’s final comments
Thomas A. Ban: Conflict of interest
Marketing vs Education
A Collated document by Thomas A. Ban
We received two final comments on the collated document of this project, which includes the transcript of the essay and the exchange that followed its posting, one comment from Ernst Franzek and another from Edward (Ned) Shorter. It is my privilege to answer both before the final collated document is converted into an Educational e-Book.
Ernst Franzek’s comments are focused on the original essay. He recognizes the contrary objectives of marketing and education. To establish a proper balance between them, he emphasizes the need for teaching “differentiated psychopathology” in the training of psychiatrists in order to open up the possibility to identify subpopulations within consensus-based diagnoses responsive to one or another pharmacological treatment<s>s</s>. Ernst notes that “replacement of single-center isolated clinical studies by multi-centers, centrally coordinated investigations” deprived these studies of the clinical observations of experienced psychiatrists” and suggests “to go back to the clinical roots by abandoning multicenter studies with high statistical power, but lack of clinical relevance insofar as individual patients are concerned." Whether one would need to revert to single center studies to get clinical relevance of findings is a moot question. It would probably be more important to understand that in conditions for which other treatments are available, the demonstration of therapeutic efficacy of a substance without identification of the treatment responsive subpopulations or demonstration of advantages in terms of side effects is exclusively to marketing interests.
In contrast to Franzek’s final comment in which clinical, educational and research issues relevant to conflict of interest between marketing and education are discussed, Edward Shorter in his final comments provide a fast moving overview of the exchange. It reads like a drama with direct quotations from the participants that culminates in a finale in which all the divergent views are reconciled. It is unfortunate that in this elegant presentation the essence of this exchange is missed. Thus, Ned writes: “I have one critical remark: This fast-moving and thoughtful exchange ignores that the greatest barrier to achieving clinically homogeneous trial populations is not sell-out academics but the DSM. Such diagnostic constructs as ‘major depression’ are hopelessly heterogeneous, but it occurs to few academics to unpack this unitary ‘depression’ (or unitary ‘schizophrenia’) in order to study drug effectiveness properly.”
After reading Ned’s comment, one wonders what we did wrong since the central point of this exchange is exactly what, in his perception, is missing from this exchange.
To ascertain that there is no misunderstanding, a direct quotation from the original text reads: “In the current state of confusion, the contrary objective of education to marketing no longer provides the necessary balance for the optimal use of psychotropic drugs. The blurring of education with marketing has created a situation in which educators in pharmacotherapy may inadvertently pursue activities in conflict with their fiduciary interests. Addressing monetary incentive alone in this confound, an ethical-legal issue, however important it is, distracts attention from the heart of the problem: that until the pharmacological heterogeneity within the diagnostic groups is not resolved pharmacotherapy with psychotropic drugs will inevitably be dominated by marketing interests.
"Insofar as pharmacotherapy with psychotropic drugs is concerned, the pharmacologically heterogeneous diagnoses have restricted the relevance of pharmacodynamic information generated by neuropharmacological research to the side effect profile of psychotropic drugs. And, insofar as neuropsychopharmacology is concerned, the lack of pharmacologically valid psychiatric diagnoses has deprived neuropharmacological research from clinical feedback to the extent that no clinically more selective or effective pharmacological treatment has developed since the introduction of the first set of therapeutically effective psychotropic drugs in the 1950s."
June 15, 2017