reform, or accept your fate…

Posted on Wednesday 30 May 2012

DSM-5 Costs $25 Million, Putting APA in a Financial Hole
Huffington Post
by Allen Frances

The American Psychiatric Association just reported a surprisingly large yearly deficit of $350,000. This was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5. APA reserves are now below "the recommended amount for a non-profit [reserves equal to a year’s operating expenses]." APA has already spent an astounding $25 million on DSM-5. I can’t imagine where all that money went. As I recall it, DSM-IV cost about $5 million, and more than half of this came from outside research grants. Even if the DSM-5 product were made of gold instead of lead, $25 million would be wildly out of proportion. The rampant disorganization of DSM-5 must have caused colossal waste. One obvious example is the $3 million spent on the useless DSM-5 field trial, with its irrelevant question, poorly conceived design, and embarrassing results.

Because APA is left holding these huge IOUs, it will be doubly desperate to begin recouping on its misguided investment. The bad financial report will ratchet up the pressure to publish DSM-5 in its current, sorry state as scheduled next May, despite the fact that it has badly flunked its own field test and now still requires extensive editing and retesting before being anywhere near fit for use.The only way to restore credibility to DSM 5 would be postpone its publication until it can be done right. This means reinstating the quality control step that was cancelled when DSM-5 kept failing to meet its own deadlines. Prematurely publishing a poor-quality DSM-5 would be nothing less than a cynical business ploy, violating what should be APA’s sacred duty to protect the public trust.

From the very start, APA treated DSM-5 as a private publishing asset meant to drive profit. Rather than encouraging the necessarily open process that Bob Spitzer recommended, all DSM-5 participants were forced to sign confidentiality agreements, to protect its "intellectual property," as if this should ever trump getting out a quality DSM-5. APA is remarkably alert and aggressive at protecting its trademark and copyright but surprisingly slack and sloppy in doing what needs to be done to produce a document anyone can trust at a price the association could afford.

Were any more proof needed that APA has forfeited its right to monopoly control of psychiatric diagnosis, this is the smoking gun. Psychiatric diagnosis has become too important to be left in the hands of a small, withering, cash-strapped, incompetent association that feels compelled to regard its bottom line as a higher priority than having a safe, scientifically sound, and widely accepted diagnostic system. The overall message couldn’t be clearer: APA has forfeited its right to hold the monopoly over psychiatric diagnosis. Guild interest should never trump public interest. Psychiatry and psychiatrists shouldn’t be judged by the DSM-5 fiasco. The field is far better and deserves far better than its past leadership. It remains to be seen if the new APA leadership will clean house and insist that DSM-5 not be published before it can be trusted.

I wouldn’t argue with Allen Frances for a second. Thus far his predictions are dead on [I’m expecting a report next year about whether he sees his shadow on Groundhog day]. Up until now, he has been the APA’s best friend in that he’s trying to keep them from self destructing, in spite of the lousy reception they’ve given him. And this sounds like he’s thinking they’re deaf and about to go off the cliff for a short term gain – revenues. But rhetorically, if I were Jeffrey Lieberman, president elect, looking at the state of play, with the miserable Field Trials looking me in the eye, and these graphs spread on the table, I think I’d have some different kinds of thoughts.
I’d look at the small droop in the DSM-IV sales as expected with a coming new manual. I’d look at the falling Pharma Revenue as expectable with an empty pipeline. I’d see the DSM-5 costs as a horror and shudder. But I’d look at the other three graphs as trends – a vote of no confidence from a dwindling membership.  Psychiatry needs an infusion of something right now, and I think it’s called Integrity.

Psychiatrists read the same newspapers you and I read. They know about Senator Grassley, and Charlie Nemeroff, and TMAP, and the big Pharma settlements. A lot of them know they’ve been sold down the river. They don’t like hearing ‘all you want to do is push pills‘ all the time. So my read of the tea leaves is that psychiatry could use a big dose of Integrity and some semblance of real leadership instead of more pablum, future dreams, and Tom Insel clinical neuroscience babble.

If Jeffrey Lieberman and the Trustees do what Allen Frances thinks they’re going to do, they’ll face a sizeable DSM-5 Boycott and a spike in ICD sales across town. And they’re going to be strapped with this DSM-5 perhaps forever, because something else will replace it. And, by the way, those falling graphs will just keep falling. So besides being the right thing to do, putting the brakes on and rethinking the DSM-5 altogether would head off obsolescence as well as offer an opportunity for psychiatry to retool with Integrity and shake out the cobwebs of decades of misadventure. Dr. Frances is probably right, but sometimes in a crisis, people rise to the occasion. If they don’t have it in them,  it’s theirs to throw away. The window is closing fast. Reform, or accept your fate, APA…
    May 30, 2012 | 10:32 PM

    “a small, withering, cash-strapped, incompetent association” — wow, talk about heaps of scorn from Allen Frances.

    I just asked a psychiatrist if he was going to buy the DSM-5. He made a face and said the APA has psychiatrists over a barrel, he has to buy it.

    How is this? Don’t psychiatrists have the option of using ICD-9 diagnoses?

    May 30, 2012 | 10:38 PM

    I think the option is there, but they may have to be told about it. That’s probably a task to put in the pipeline if the APA keeps heading for the cliff…

    May 30, 2012 | 10:48 PM

    The ICD 9 and 10 are used in medical billing, I doubt the DSM 5 will be completely necessary…

    Take a look at Todd Finnerty’s blog about this :

    Let’s not “prop up” The American Psychiatric Association anymore

    He’s running for the Pres of Amer Psychological Association

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