Psychiatry: from interest in conflicts to conflicts of interest.

There was a time when psychiatry was largely influenced by the view that most mental conditions were the result of unsolved inner conflicts. That was a time when the availability of effective drugs for psychiatric disorders was extremely limited, and access to mental health care was also restricted to the very wealthy or to very sick patients, who would be confined in institutions for the mentally ill for long periods of time, and kept apart from society. The emergence of psychopharmacology rapidly changed this panorama, but it has carried novel challenges, not only for clinical practice, education and research, but also for doctor-patient relationships. These changes go in parallel with those of modern societies, increasing the distance between developed and struggling countries, and raise further ethical concerns. This is why I believe that the debate on conflicts of interest, particularly for the financial ones, is difficult to separate from ideology/politics, and this is why I think that we should take a global approach to it. Hence, as Giovanni Fava rightly points out, clinical medicine and psychiatry are suffering from an unprecedented crisis of credibility, and this has more to do, in my opinion, with increased awareness about this issue rather than with decreased ethical standards or malpractice. Our society is increasingly aware of potential conflicts of interest and this is good for transparency, although one of my arguments will be that some conflicts are more visible than others and, to be fair, our responsibility as clinicians, educators or researchers is to disclose all of them, regardless of their nature. At the end of the day, having a potential conflict of interest is not the same as being necessarily biased or corrupt. Psychiatry has taught that avoiding conflicts is not generally the right way to solve them.