giving it away…

Posted on Wednesday 23 January 2013

Sometimes, it’s not the weight of a single piece of evidence that confirms an impression, a diagnosis, or a jury’s decision. It’s a series of things that rises above being just a suspicious trend into the range of an obviously motivated pattern. In my own criticisms of the DSM-5, I’ve stayed away from allegations that it is a "cash cow" for the American Psychiatric Association, primarily because I’ve been a non-member for so long that I thought it was presumptuous of me to weigh in on their inner workings. But it hasn’t been lost on any of us that the APA membership is waning and their income stream has been further constricted by a falling contribution from the pharmaceutical industry. But whatever the institutional need, this is simply an affront:
Price Gouging: Why Will DSM-5 Cost $199 a Copy?
Because it thinks it has a monopoly but probably doesn’t
Psychology Today
DSM5 in Distress

by Allen J. Frances, M.D.
January 23, 2013

DSM-5 has just announced its price -an incredible $199 [and the paperback is also no bargain at a hefty $149]. Compare this to $25 for a DSM III in 1980; $65 for a DSM IV in 1994; and $84 for a DSM-IV-TR in 2000. The price tag on a copy of DSM is escalating at more than twice the rate of inflation. What’s going on? No one outside the closed APA circle will ever really know for sure, but clearly the astounding price jump is not fueled by Adam Smith’s ‘invisible hand’- the powerful interaction of supply and demand that guides any free market.

The supply of DSM-5 is unlimited [APA would love to print all the copies it can sell] while the demand is likely to be quite limited [due to all the mistrust that has been generated by DSM-5’s flawed process and reckless product]. So if supply is great and demand is small, why is the price of DSM-5 jumping up so rapidly instead of sticking to inflation or retreating? Three reasons:

  • First, APA has sunk more than $25 million into DSM-5 and wants to recoup as much of its investment as it can. God only knows where the money went. DSM-IV cost one fifth as much- just $5 million- of which half came from external grants.
  • Second, APA is in deficit and is rapidly losing membership dues and drug company funding. It desperately needs all the publishing profits it can pull from DSM-5 to bridge its budgetary gap. If DSM-5 sales are projected to be much less than originally expected, the APA strategy may be to raise prices sky high in order to make up the difference.
  • Third, APA is probably counting on having captive buyers who are forced to pay its price, however exorbitant it may be. That’s exactly how monopolies take advantage of markets that are not free – rigging the prices to bring in all the profits the helpless traffic will bear.
I can hardly wait for the APA’s retort to this post by Dr. Frances. They sometimes put together some piece of twisted logic to explain themselves. Like the attack on Suzy Chapman’s blog domain [DSM-5™…], this one is indefensible. Says Dr. Frances:
I predict that APA’s pricing decision is just the latest in its long series of DSM-5 miscalculations. Four facts suggest this is a market that will not be held captive:

  • DSM-5 boycotts are sprouting up all over the place
  • The codes clinicians need for insurance purposes are available for free on the internet
  • DSM-5 is so clunkily written, no teacher will ever want to assign it to students
  • People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound.

The exorbitant price for DSM-5 will be just another reason, were any needed, for buyers to abandon it. The good news is that its lowered sales and lost credibility will limit the damage that can be done by DSM-5. The bad news is that we will no longer have a consensus method of making psychiatric diagnoses. Previous systems [DSM-III, DSM-III-R, DSM-IV] were far from perfect, but they were good enough to provide a widely accepted common language for communication. The gross incompetence of DSM-5 will likely return us to a Babel of many languages – different people using different methods of diagnoses.

My warnings to DSM-5 during this past four years were intended to avoid precisely this outcome. Unfortunately, I failed in my attempt to get them to hear and they failed to listen.
Yesterday, I was writing about a personal observation about life in the segregated South of my youth [the day the music died…]. Although I would’ve told you earlier in my life that segregation was wrong and even had those arguments with classmates as a child, it wasn’t until I got out of my world and saw it somewhere else that I realized how very wrong it really was. The same thing happened after the tumult of the 1980s when I left academic psychiatry and the APA. On any given day, if asked I would’ve talked about the psychiatry being on a very wrong path, that medication was being massively overused, but it wasn’t until I retired and took a look back that I was able to see how far off the path we’d wandered. For that matter, it took a similar distance to see how psychoanalysis had hurt the cause of psychotherapy by rigidly holding to its policies about third party payments and overstating its explanatory or therapeutic power. That must be a general human frailty – being unable to see things that ought to be as plain as the nose on your face because they’ve just become part of the surround.

The generation of psychiatrists in charge of the DSM-5 spent their careers in a psychiatry that really did see the DSM-III as a bible and the ascendency of a purely biomedical psychiatry being just over the horizon. They grew up in a psychiatry where affiliations with industry were not only allowed, they were encouraged. And they assumed that the place of psychiatry among the various mental health professions was a given rather than earned. The internal dissent of the previous generation had been dealt with in 1980 by the APA whose power became analogous to that of the Soviet Central Committee of old. Even in the face of numerous scandals at the top, they carried on with little comment. And I expect they see their critics as gadflies with some kind of discountable agenda that will simply pass if ignored. They’re living in a bubble and apparently don’t know it. It’s not only an isolation bubble, it’s a bubble like the housing bubble – an illusion ready to burst.

That’s the only way I can understand their thinking that they can sell the DSM-5 to people for the exorbitant price of $199/book. At the rate they’re going, they may have trouble giving it away…
    January 24, 2013 | 12:19 AM

    The AMA claims to be in agreement with the tenants of the Sunshine act; but it appears clear that the APA will have to be dragged kicking and screaming into reforming itself.

    The administration has been recouping billions of dollars every year by cracking down on medicare/medicaid fraud. A good portion of that money is coming out of the hides of the pharmaceutical companies, nursing homes. and hospitals that dispense anti-psychotics to vulnerable people who don’t need them in the first place and are being harmed and killed by them. Right now a structure is being built to challenge medical professionals who are working for themselves instead of the well-being of their patients.

    Our government has had the same basic structure since the 1940’s. This administration is working very hard and very competently to build the architecture to hold the leviathan of contemporary medicine to a reasonable standard. None of it was ever going to be fixed in four years or less.

    Recognizing the progress that has been made, and going straight to the horse’s mouth (white house dot gov) can actually be consoling. Anyone can send an e-mail to the President’s office any time, and ask for a response; which I highly encourage you to do, Mickey. Your voice and experience is very valuable and a breath of fresh air. You especially have a lot to say about what works for people who are suffering under the yoke of poverty and isolation.

    Managed Care Organizations as Well as Pharma?
    January 24, 2013 | 1:30 AM

    “Using a checklist to make a rapid diagnoses (in minutes) and rapidly treat large numbers of patients is promoted by managed care organizations and HMOs. That is probably the single greatest factor contributing to antidepressant prescriptions but it is ignored by the author – probably because it challenges his contention that this is all driven by conflict of interest in psychiatry rather than the business world. It is cheaper for HMOs to treat depression with medications rather than detailed psychiatric assessments and psychotherapy.”

    “But who really has an interest in treating all anxiety like a medical problem? I have previously posted John Greist’s single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy. In the meantime, what has the managed care cartel been doing? Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner. The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed. The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment.”

    Managed Care Organizations as Well as Pharma?
    January 24, 2013 | 1:33 AM

    “Our profession is under assault from big business, and finding clarity is the shield we need to defend society and our patients.”

    Managed Care Organizations as Well as Pharma?
    January 24, 2013 | 1:56 AM

    “Organized psychiatry is certainly not responsible for what happens in primary care clinics under the direct guidance of business organizations.”
    “In 1991, Dr. Nemeroff became Chairman at Emory. That year, he had testified as an expert for Eli Lilly at an FDA hearing about Prozac and suicidal thinking [he said it didn’t happen]. In 1993, Sally Laden of STI [who would later ghost-write the Study 329 paper] organized SKF’s Paxil Advisory Board to meet in November 1993 and chose Dr. Nemeroff as moderator. The main focus of the meeting was on getting Primary Care Physicians to treat depression [with Paxil]. Sally Laden’s STI would later ghost-write Drs. Nemeroff’s and Schatzberg’s 1999 textbook for Primary Care heavily weighted towards Paxil [come to think of it, Dr. Schatzberg also became Chairman at Stanford in 1991].”

    berit bj
    January 24, 2013 | 8:34 AM

    A tsunami is building up, I think. Too many victims, families and responsible professionals are reading the devastating signs of big-business-medicine, most of all in bio-psychiatry, like the young British girl on a beach in Thailand, saving scores of people when screaming out to tell others the meaning of a receding ocean. Trust in psychiatry is at an increasingly low ebb. The ghosts are out and can’t be put back in the bottle. Even Nazi thugs knew to hide the truth of their eugenic practices on disabled people from the victims’ families. Even Philip Zimbardo’s famous prison experiment was stopped short, not by the researcher-in-chief himself, but by his wife, telling him to stop rapidly escalating violence. The Lucifer Effect…

    January 24, 2013 | 10:36 AM
    January 24, 2013 | 1:17 PM

    When pharma money primed the pump, conflict of interest was rampant, now overprescription of psychiatric drugs is incorporated into managed care guidelines zealously defended by empire-builders of another stripe.

    Consistently absent throughout all of this is protest by psychiatry’s professional organizations. One can only wonder why, since over-reliance on prescribing drugs has clearly devalued the expertise of psychiatrists.

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