Views & Reviews From the Frontline

The perils of commissioning bias

BMJ 2008; 336 doi: (Published 07 February 2008) Cite this as: BMJ 2008;336:332
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

    The late Friday night debriefing in the kitchen: “You’re not listening.” I have that male trait of being easily distracted by other ideas.

    She was right, but fortunately we’d had this discussion many times. “Well, you believe that ADHD is not a ‘condition,’ but an evolutionary trait of men. That boys need exercise to function and that in modern society, and in particular our education system, this is lacking. Boys are like puppies—coop them up, and they will chew the legs off your furniture and shred the newspaper. That vigorous exercise should be used to ‘treat’ this ‘condition.’ You based this argument on our three boys and being a vet. Is that about right?” I replied. She beamed a red wine smile.

    Could she actually be right? After a blurry eyed trawl of Medline and the Cochrane database, I found nothing on exercise as an intervention—just thousands of papers on drug intervention. She scowled when I told her she was wrong.

    But at 3 am my hyperactive brain buzzed me awake, a flashing neon sign read “Commissioning Bias.” She wasn’t wrong. It is that no one has ever bothered to commission the research. Simple: no research, no evidence. I fidgeted as I stared at the ceiling. The overwhelming majority of research is commissioned by pharmaceutical companies, which have the motivation and wealth to do so. But they then own the data, restricting access and thus allowing data to be spun in the most convincing ways. Therefore, there is a gaping flaw in medicine, as it completely skewed towards drugs by this commissioning bias.

    Commissioning bias operates in all clinical areas, but especially the drug industry’s golden geese of chronic diseases. The greatest effects are felt in mental health. We live in a psychotropic police state—the diazepam cosh in inner cities, antidepressants in the melancholic suburbs, and now the sickly amphetamine cocktail being offered to 10% of our children. All these interventions are the result of an unstoppable tsunami of positive drug company research.

    But when this wave inevitably falls and crashes to the ground decades later, it is too late—the social devastation is complete, with the chaos of diazepam dependence and the medicalisation of mood with all its negative sequelae. We won’t know the effects of prescribing in attention-deficit/hyperactivity disorder for at least a generation, but I fear that when we do it will be too late for that generation of children and adults—and all dissenting voices and alternative psychological hypothesis long drowned and smashed by the simplistic power of “the evidence” wave. Commissioning bias has perverted and distorted medical care but isn’t even being discussed within the academic and medical community.

    Is my wife right about exercise in ADHD? Who knows, but somebody should find out, for soon it will become obvious that the drugs don’t work.

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