Letter

A Question of Disclosure

To the Editor: The May 2008 issue focusing on the results of Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) was excellent. However, I wish to take exception to the article by Dr. Duckworth and Mr. Fitzpatrick ( 1 ), who are medical director and executive director, respectively, of the National Alliance on Mental Illness (NAMI). The authors express doubts about placing any restrictions on the availability of second-generation antipsychotics, claiming that restrictions "will hurt clinical care" and that cost savings will be "illusory." Their article strongly supports the position of the pharmaceutical industry.

In the same issue the article by Rosenheck and colleagues ( 2 ) notes that second-generation antipsychotics cost $10 billion more per year than first-generation agents. I agree that all individuals with schizophrenia should be given a trial of second-generation drugs, but unless these drugs are superior for that individual, first-generation agents should be routinely used. If the newer agents are no more effective for, say, half of all patients—I am guessing here—that would be savings of $5billion a year.

Whether we like it or not, the funding of mental health services is a zero-sum game. Five billion dollars will buy a lot of case managers, social workers, clubhouses, supported employment, and supported housing. The views expressed by Dr. Duckworth and Mr. Fitzpatrick thus do not represent my views as a member of NAMI nor, I suspect, the views of many other NAMI members.

The other issue raised by Duckworth and Fitzpatrick's article is the claim at the end of the article that the authors have "no competing interests" in writing about the issue of second-generation antipsychotics. The guidelines for articles submitted to Psychiatric Services state that "conflicts of interest may be direct … or indirect…. Reporting must include all arrangements that may present an appearance of bias" and should cover "the 12-month period preceding acceptance of the manuscript." The authors in this case are both employees of NAMI, which receives more than half its budget from pharmaceutical companies. According to the Eli Lilly Web site ( 3 ), that company gave NAMI chapters 62 separate grants in 2007; in the first quarter of 2008 Lilly gave $520,000 to the national office of NAMI. These sums do not include gifts from other companies that market second-generation antipsychotics.

Thus it would seem appropriate for the authors to have acknowledged this potential conflict of interest so that readers could make their own assessment about whether the opinions expressed were the result of bias.