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Conflicts of Interest and Spin in Reviews of Psychological Therapies Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-010606 on 26 April 2016. Downloaded from Conflicts of interest and spin in reviews of psychological therapies: a systematic review Klaus Lieb,1 Jan von der Osten-Sacken,1 Jutta Stoffers-Winterling,1 Neele Reiss,2 Jürgen Barth3 To cite: Lieb K, Osten- ABSTRACT Strengths and limitations of this study Sacken J von der, Stoffers- Objective: To explore conflicts of interest (COI) and Winterling J, et al. Conflicts their reporting in systematic reviews of psychological ▪ of interest and spin in This study addresses a widely neglected research therapies, and to evaluate spin in the conclusions of reviews of psychological topic, that is, spin introduced by non-financial therapies: a systematic the reviews. conflicts of interest (COI), for example, the review. BMJ Open 2016;6: Methods: MEDLINE and PsycINFO databases were researcher’s allegiance to a specific therapy, in e010606. doi:10.1136/ searched for systematic reviews published between reviews on psychotherapy studies. bmjopen-2015-010606 2010 and 2013 that assessed effects of psychological ▪ Although authors of reviews of psychological therapies for anxiety, depressive or personality therapies frequently show COI (which mainly are ▸ Prepublication history and disorders, and included at least one randomised not declared), the relationship to spin in review additional material is controlled trial. Required COI disclosure by journal, conclusions is less clear and has to be inter- available. To view please visit disclosed COI by review authors, and the inclusion of preted with caution. the journal (http://dx.doi.org/ own primary studies by review authors were extracted. ▪ We decided to use the term ‘spin’ instead of 10.1136/bmjopen-2015- Researcher allegiance, that is, that researchers ‘bias’, although we cannot make claims about 010606). concluded favourably about the interventions they have the nature of the influence which might be mere studied, as well as spin, that is, differences between bias or more intentional spin. results and conclusions of the reviews, were rated by 2 ▪ The selection of studies up to 2013 does not Received 19 November 2015 independent raters. reflect possible changes in COI declarations in Revised 25 February 2016 Accepted 11 March 2016 Results: 936 references were retrieved, 95 reviews recent years. fulfilled eligibility criteria. 59 compared psychological http://bmjopen.bmj.com/ therapies with other forms of psychological therapies, and 36 psychological therapies with pharmacological professional judgement or action regarding interventions. Financial, non-financial, and personal COI a primary interest will be unduly influenced were disclosed in 22, 4 and 1 review, respectively. 2 of by a secondary interest.12Research on COI 86 own primary studies of review authors included in 34 has so far mainly focused on financial COI reviews were disclosed by review authors. In 15 of the such as close financial relationships between reviews, authors showed an allegiance effect to the researchers or medical doctors and pharma- evaluated psychological therapy that was never fi ceutical companies, or the nancing of drug on September 25, 2021 by guest. Protected copyright. disclosed. Spin in review conclusions was found in 27 3–7 of 95 reviews. Reviews with a conclusion in favour of trials by pharmaceutical companies. Such psychological therapies (vs pharmacological research has shown that studies funded by 1Department of Psychiatry interventions) were at high risk for a spin in conclusions pharmaceutical companies more often yield and Psychotherapy, (OR=8.31 (1.41 to 49.05)). Spin was related in trend to results or conclusions in favour of the spon- University Medical Center the inclusion of own primary studies in the systematic soring company as compared to Mainz, Mainz, Germany review (OR=2.08 (CI 0.83 to 5.18) p=0.11) and non-industry-funded trials;89that close rela- 2Department of Differential researcher allegiance (OR=2.63 (0.84 to 8.16) p=0.16). Psychology and tionships of researchers to pharmaceutical Psychological Assessment, Conclusions: Non-financial COI, especially the companies are linked to biased assessments Goethe-University Frankfurt, inclusion of own primary studies into reviews and of drug safety and efficacy;10 11 that positive Frankfurt, Germany researcher allegiance, are frequently seen in systematic 3 trials are more likely to be published than Institute for Complementary reviews of psychological therapies and need more trials unfavourable to sponsors;12 and that and Integrative Medicine, transparency and better management. University Hospital Zurich COI are under-reported in meta-analyses of 13 14 and University Zurich, pharmacological treatments. Zurich, Switzerland The influence of non-financial COI, however, on the framing of research ques- Correspondence to Dr Klaus Lieb; INTRODUCTION tions, the data analysis and interpretation klaus.lieb@unimedizin-mainz. Conflicts of interest (COI) are defined as a of results, or the decision which results de set of circumstances that creates a risk that a are being published, has been much less Lieb K, et al. BMJ Open 2016;6:e010606. doi:10.1136/bmjopen-2015-010606 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-010606 on 26 April 2016. Downloaded from extensively studied.15 With respect to outcome research an author of the respective primary study. These primary of psychological therapies, researcher allegiance consti- studies were then used to rate researcher allegiance. tutes an important non-financial COI. Allegiance covers the belief of a researcher in the superiority of a treat- Assessment of disclosed and undisclosed COI ment.16 17 Allegiance may be due to a special training in All disclosed COI were extracted: financial COI (honor- one specific psychological therapy, the involvement in aria, eg, for consulting, lectures, scientific articles, train- previous efficacy research about this psychological ing courses, or money for research projects), therapy or the involvement in development of aetio- non-financial COI (eg, researcher allegiance to a psycho- – logical models via basic research.18 20 Empirical studies logical therapy, special qualification in a psychological showed a strong impact of researcher allegiance on therapy, enthusiasm for a psychological therapy in scien- outcome in psychotherapy studies: a recent meta-analysis tific publications, lectures and research, or inclusion of showed a robust and moderate allegiance outcome asso- own primary studies in reviews), and personal COI (eg, ciation (r=0.26),21 and such an association is also employee or private relationship to an employee of a present in equally effective treatments.22 Taking alle- company—regularly addressed as relationships to giance into account for the explanation of effect differ- pharmaceutical companies). If no COI was reported, the ences between two active treatments studies with websites of the respective journals as well as the guide- balanced allegiance for two different treatments show lines for authors were screened for requirements of COI no difference in the effectiveness.23 disclosures at the time of the publication of the review. Since nothing is known about the extent and nature In addition, we assessed whether review authors of non-financial COI in systematic reviews of psycho- included own studies on psychological therapies into logical therapies, the aim of this study was to investigate their review, and whether this inclusion was disclosed. how often non-financial COI are present and disclosed in systematic reviews of psychological therapies, and to Rating of researcher allegiance analyse whether these COI increase the risk of spin in In case that a review author included at least one own the conclusions of the reviews. primary study (which he or she coauthored) into the review, we retrieved these primary studies and rated the researcher allegiance according to information pre- METHODS sented in the primary study (note that a rating of Search strategy and eligibility criteria of systematic researcher allegiance was not possible in the reviews reviews since these do not provide essential information to rate We searched the MEDLINE and PsycINFO data bases researcher allegiance according to established stan- 18–20 for systematic reviews or meta-analyses of randomised dards). Researcher allegiance was rated in 73 of the http://bmjopen.bmj.com/ controlled trials (RCT) on psychological therapies. 86 included primary studies since 13 reviews did not Reviews were selected if they fulfilled the following inclu- compare psychological therapies to other treatments sion criteria: (1) inclusion of psychological therapies to and were therefore excluded. fi treat patients with anxiety disorders, personality disor- Researcher allegiance was de ned to be present if the ders and/or major depressive disorders in adults, (2) author (1) recommended the respective psychological active control groups with either other forms of psycho- therapy over another therapy and was (2) either involved logical therapy or pharmacological interventions, (3) in the development of the respective psychological inclusion of at least one randomised study and (4) therapy, or (3) was involved in research of/development on September 25, 2021 by guest. Protected copyright. English language. Searches were last run on 3 February of the aetiological model of the psychological therapy. 2014, covering the publication period of January 2010– Two independent researchers ( JvdOS, JB) assessed
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