Ethical issues related to outpatient commitment and drug industry
relationships were among the many thorny psychiatric issues with which experts
wrestled at APA's ethics workshop for district branch executives and chairs of
The biennial workshop was held last month in Washington, D.C., prior to the
fall meeting of the Assembly and was sponsored by APA's Ethics Committee. The
goal was to educate district branch ethics chairs and executive staff about
APA's "Procedures of Handling Complaints of Unethical Conduct" and
key ethical issues so they can more effectively deal with ethics issues at the
As psychiatrists continue to struggle with many complex ethical questions,
recent events and news coverage have given some questions increased
One of those questions concerns the ethically appropriate uses of
outpatient commitment. Such use has been urged in the wake of the April
killing of 32 students and professors at Virginia Tech by a student with
mental illness. The 23-year-old student, who ended his rampage by killing
himself, had been involuntarily committed to a psychiatric hospital in 2005
after two women students complained about his behavior to campus police, and
he sent friends an instant message implying he was suicidal. He was released
after a doctor at the hospital said he was mentally ill but not an imminent
In the wake of the killings, legislators and others in Virginia and other
states have pushed for stricter outpatient civil commitment laws under which a
larger number of people with mental illness could be committed. The also have
urged review of laws and university regulations governing privacy to ensure
they have not been misinterpreted.
Paul Appelbaum, M.D., chair of APA's Council on Psychiatry and Law, says
that civil commitment laws are failing in many states because of inadequate
funding for mental health services and follow-up.
Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and
Law at Columbia University, said the gunman had been deemed suitable for
outpatient commitment, but there was never any follow-up. The reason the
Virginia law failed and many other states' civil commitment laws would have
been similarly ineffective, he said, is because state governments don't
provide funding for the appropriate number of mental health personnel needed
to track such individuals, and they don't fund the psychiatric beds to enforce
mandatory treatment of those who do not comply with outpatient care.
Some states have begun to allocate greater resources for better enforcement
of their civil commitment statutes, however, which raises the ethical question
of whether limited resources should be concentrated on a small number of
patients or spread more broadly to benefit a greater number through other
"Does outpatient commitment shift resources from those who want it to
those who don't want it and are treatment resistant?" asked Appelbaum,
who is chair of APA's Council on Psychiatry and Law.
But how often should states require coercive treatment? Increasingly,
states have generally addressed the thorny ethical question of how much
individual liberty to constrict to protect the public through outpatient
commitment laws, while lacking funding for inpatient care or outpatient
The result has been many outpatient commitment laws that lack any real
enforcement mechanism. Without a comprehensive approach, civil commitment
statutes "cannot protect the public from rare acts of violence by people
with mental illness," Appelbaum said.
Another area of ethics that has grabbed the public's attention in recent
years has been the issue of physicians' relationship with the pharmaceutical
industry. APA has attempted to address the public's concerns about this
relationship as it begins work on DSM-V by instituting an in-depth
industry-relations disclosure, divestiture, and confirmation process for
psychiatrists being considered for appointment to work on DSM-V,
according to Donna Norris, M.D., secretary-treasurer of APA. The inherent
intrusiveness of the process has drawn complaints from some, and several
psychiatrists have refused to contribute to the DSM-V process because
of it; however, many others have successfully completed the requirements of
the disclosure process.
APA President Carolyn Robinowitz, M.D., discusses the complicated ethics
of the relationship between physicians and drug makers.
Johnson Photography 2007
The issue of industry affiliations also applies to individual
psychiatrists, said Carolyn Robinowitz, M.D., APA president.
"We are living in an age where we do have to question whether pharma
is our friend or our foe," Robinowitz said.
The greater importance and effectiveness of pharmacotherapy in recent
decades, coupled with the role of industry as the primary funding source of
psychiatric medication research, have created strong bonds between industry
and medicine. Third-party payers also have encouraged the greater use of
medications stemming from a single visit, instead of talk therapy over many
"And patients often prefer less time spent in a doctor's office and
more of the magic that newspaper advertisements and movies tell us about
medications," she said.
Differentiations between education and marketing became entangled because
drug companies traditionally undertake new drug development and disseminate
much of the information about new medications and newer uses for older
"They want people to use their product properly, but they also want
people to use their products, and sometimes those are a bit in
conflict," Robinowitz said.
In response to a question from Robinowitz about who received what free drug
samples from manufacturers, only one audience member said they had received
generic as well as name-brand samples.
David Baron, M.D., chair of the Ethics Committee of the Illinois
Psychiatric Society, was among the many district branch officials who posed
complex questions to presenters at APA's 2007 ethics workshop.
©Sylvia Johnson Photography 2007
The questions surrounding industry promotion should not be allowed to
overwhelm the advocacy role of psychiatrists, which entails informing the
public that treatment works and is available and affordable. It is important
to remember, she said, that the research shows that the best patient outcomes
often stem from a combination of medication and talk therapies.
Increasing questions among policymakers and the media about the influence
of the drug industry on clinicians' pharmaceutical prescribing patterns mean
that psychiatrists need to be as circumspect and as open as possible. If the
public is convinced that conflicts exist, then policymakers will enact overly
simple "solutions," or patients will lose trust in their
clinician's treatment plan.
"We need to be clear about what we do so that the science doesn't get
tainted. That's the bottom line," Robinowitz said.
She called for specific steps to clarify the role of industry. One step
would have psychiatry residents meet with an industry representative and a
senior faculty member "who understands the literature and who can help
them evaluate and assess what they are being told," which will help them
develop critical thinking and assess what they are told by drug makers.
Robinowitz urged individual psychiatrists to disclose industry
relationships as fully as possible, while avoiding the use of company-provided
items that feature drug names or manufacturer names. Any industry-funded
presentation meals are marketing, she said. And presenters should always
disclose any industry funding they have received.
Researchers also can avoid ethical conflict allegations by making sure they
register, review, and report industry relationships. The Association of
American Medical Colleges responded to growing concerns about researcher
conflicts in recent months by issuing specific principals to maintain the
integrity of clinical research.
"We need to educate people about these relationships and about
critical evaluation and prohibit inappropriate participation,"
Robinowitz said. ▪