Posted on Thursday 16 January 2014

What follows is a letter to the APA Assembly members that appeared on the APA website on Tuesday. I’ve posted it below for your perusal. It’s so far off the mark that it’s hard for me to respond to so I’ll defer that for the moment and stick to what it doesn’t do.

For the extent of his tenure as Chair of the DSM-5 Task Force, Dr. Kupfer, his wife Dr. Ellen Frank [a member of his Pittsburg faculty and the DSM-5 Mood Disorders Group], and another of his University of Pittsburg faculty, Dr. Paul Pilkonis [a consultant to the DSM-5 Instrument Assessment Study Group] have collaborated with Dr. Robert Gibbons [also a consultant to the DSM-5 Instrument Assessment Study Group] to develop Computerized Adaptive Tests that measure "dimensions" [anxiety and depression]. Both before and during the Revision process, Dr. Kupfer has strongly advocated for including "dimensions" in the DSM-5 classifications. The "dimensions" were only removed from the manual proper to Section 3 [further study] in the final approval meeting of the Board of Trustees in December 2012. The tests developed have been officially a commercial product since at least November 2011 [with Gibbons, Kupfer, Frank, and Pilkonis as stockholders]. None of the principles [Kupfer, Frank, Gibbons, or Pilkonis] declared this clear COI publicly until after the DSM-5 had gone to press in December 2012. And it wasn’t common knowledge until July 2013 when it was discovered after they accused a critic of a COI [which had, in fact, been declared].

The letter below plays around legalistically with the timeline and the details, but completely ignores the most obvious of points. Why was this multifaceted tangle of Conflicts of Interest kept secret until the DSM-5 process was ended? Why did Dr. Kupfer who repeatedly defended the DSM-5 Task Force’s transparency not declare this one? How could Dr. Kupfer in good conscience, participate in writing letters to Dr. Allen Frances and recently to Dr. Bernard Carroll accusing them of COI when he was sitting on this? I suppose there’s a further question. Is this letter the APA’s final investigation of this story? Is there no higher standard for someone with a position at this high level? While there a number of inaccuracies in this letter, the failure to even address the central issue here is beyond disturbing.

January 14, 2014

Dear Assembly Members,
I was recently made aware of a conflict of interest disclosure issue involving Dr. David Kupfer and his ownership interest in a company called Psychiatric Assessments, Inc. [PAI]. Upon receipt of this information, I took the matter to the Board of Trustees. The Board of Trustees and APA leadership take conflict-of-interest principles and guidelines very seriously. They instructed APA staff to review the matter and report back their findings. Below is a summary of the situation with APA’s findings.

Mindy Young, MD
Speaker of the Assembly
American Psychiatric Association


    Dr. Bernard Carroll and others in recent blog postings and listserv conversations questioned:
    1. whether Dr. Kupfer’s ownership interest in a company called Psychiatric Assessments, Inc. or PAI, was disclosed to APA;
    2. whether that PAI interest influenced the DSM-5’s decision to include dimensional measures in Section 3 for further study; and
    3. whether DSM-5’s inclusion of dimensional measures gives any product PAI may create a more favorable commercial advantage because of Dr. Kupfer’s role as chair of the DSM-5 Task Force. We also reviewed disclosures in the American Journal of Psychiatry [“AJP”] and JAMA Psychiatry.
    From 2002-2011, Dr. Kupfer, Dr. Frank, and Dr. Gibbons and several others, who were not involved in DSM-5, worked on an NIMH grant to create Computer Adaptive Tests [CAT] based on multidimensional response theory. Dr. Gibbons was the principal investigator and subcontracted with the University of Pittsburgh on the grant. Drs. Kupfer and Frank worked on the grant through the University of Pittsburgh. This grant resulted in several tests being developed. In November 2011, Dr. Gibbons formed a company, PAI and on January 3, 2012, Dr. Gibbons gave a 5% interest each to four people involved in the NIMH grant, including Drs. Kupfer and Frank, who are spouses. Dr. Ellen Frank was a Member of the Mood Disorders Work Group, and Robert Gibbons, PhD was an advisor to the Diagnostic Assessment Instruments Study Group for DSM-5. After reviewing the blog and listserv postings, interviewing people involved with instrument selection for DSM, reviewing the literature, internal documents relating to DSM-5’s recommendations on dimensional measures, and conflict of interest policies and disclosures, APA has drawn the following conclusions:


  1. APA’s conflict of interest forms called for disclosure of any financial interest, including stock ownership, in any company related to the field of psychiatry.
      We believe that Drs. Kupfer, Frank and Gibbons should have disclosed their interest in PAI on APA’s conflict of interest form in 2012, and they did not do so. Dr. Kupfer did include his stock ownership in PAI on his April 2013 disclosure. Even though PAI has no product or revenue, and never has had a product or revenue, it is a company related to psychiatry and the stock interest should have been disclosed.
  2. The stock interest in PAI did not influence DSM-5’s move toward dimensional measures.
      Use of dimensional measures dates back to the 1960s and the Hamilton Depression Scale. The Patient Health Questionnaire-9 [PHQ-9] scale was developed for DSM-III’s diagnosis of major depressive disorder by Dr. Spitzer and his colleagues. DSM-IV, released in 1994, discussed the benefits of dimensional measures. And, before the DSM-5 Task Force was formed, beginning in 2003, there were entire conferences dedicated to exploring the use of dimensional measures in DSM-5. The dimensional measures used in field testing were selected by the end of 2010 – over a year before PAI was formed. Drs. Kupfer, Gibbons, and Frank did not advocate for inclusion of CAT in DSM-5. Their work on CAT was well known to the DSM-5 Instrument Study Group because of the NIMH grant and their publications, but it was not considered viable for DSM-5 because of its complexity and immaturity.
  3. PAI will not gain financially from DSM-5’s inclusion of dimensional measures in Section 3 or if CAT is included in future versions of DSM.
      If and when PAI develops a commercial product with CAT, it will not have any greater advantage because of DSM-5’s inclusion of dimensional measures in Section 3 than the dozens of dimensional measures currently being marketed by others. If CAT is developed commercially, PAI will not gain any special financial benefit if included in DSM because APA’s policy is to not include any measure in unless the owner agrees to provide it for free to clinicians and researchers.
  4. Drs. Gibbons, Frank and Kupfer disclosed their interest in PAI publicly in AJP before disclosing it in JAMA Psychiatry..
      Drs. Gibbons, Frank, Kupfer and others who worked on the NIMH grant published an article on CAT-Anxiety in August 2013 in the American Journal of Psychiatry, which included disclosure regarding their ownership interest in PAI. Thus, in APA’s journal, there is no disclosure issue. The non-disclosure issue arose in connection with a JAMA Psychiatry article. We understand the facts to be as follows. Drs. Gibbons, Kupfer, Frank and the other NIMH investigators submitted a paper on CAT for publication in JAMA Psychiatry in August 2011 – three months before PAI was formed. The article was published over a year later in November 2012 with the disclosure that “The CAT-DI will ultimately be made available for routine administration and its development as a commercial product is under consideration.” In November 2013 – three months after disclosure in AJP, the authors published a letter entitled “Failure to Report Financial Disclosure Information” in JAMA Psychiatry. The details of that disclosure and whether it satisfies JAMA Psychiatry’s standards are between the authors and JAMA Psychiatry.
    Dr. Kupfer should have disclosed to APA his interest in PAI in 2012. Dr. Kupfer’s interest in PAI, which came after the decision had been made to include dimensional measures in DSM-5, did not influence DSM-5’s inclusion of dimensional measures for further study in Section 3. Interest in inclusion of these measures in DSM-5 began with conferences starting in 2003. If and when PAI develops a commercial product with CAT, it will not have any greater advantage than the dozens of dimensional measures currently being marketed by others.
    January 16, 2014 | 4:37 PM

    Yep. These people are ripe for analysis. At this point, the industry needs to be taken to the woodshed by philosophers— not just for ethics, but to be required to examine their place in the sciences. The biological model of mental illness is part of a greater misstep made possible by people idolizing the sciences and letting scientists and scientificists take over academic and medical territories they’re not qualified to influence, much less define.

    Materialism and reductionism is spoiling our scientific culture enough, as it is, using lame rationalizations to excuse themselves and each other from corruption for the “good” of their subjects is ugly and symptomatic of a very self-aggrandizing, dishonest, dishonorable, and greedy milieu.

    It’s going to take a lot of forces from different perspectives to stop this corrupt, delusional, and conveniently unaware “it” of psychiatry from doing the damage it is doing and to give the myth of biological determination the long dirt nap it’s due.

    January 16, 2014 | 6:20 PM

    Just started reading the book “Mistakes Were Made (but not by me)”. Seems it will be relevant.

    Steve Lucas
    January 17, 2014 | 8:00 AM

    I was reminded that many years ago I was taught salespeople are never wrong, and that the money you have belongs to them for their use. They live in the moment so that what is right and true this moment may be wrong a moment late in the same conversation. Recent list of psychopaths have salespeople near the top.

    What brought this to mind was my wife and I are dealing with some very aggressive phone solicitors involving oil and gas investments. Telling them no and do not call again only brings a different person calling and they are spoofing our caller id to show the last incoming call. I am sure they feel they have a great investment and the commission they will receive is money we owe them for bringing this to our attention.

    These doctors seem to have the same mindset. They have such a great idea that any money they receive is owed them and any slight of hand is for the great good. Their greater good.

    We all need to move away from the concept that doctor’s are by nature good. They represent a cross section of society like any other group, and like any other group we will find those who do not have others best interest at heart. The simple fact is these doctors feel they are owed their financial rewards simply because they are who they are, and for no other reason.

    It would be interesting to see how closely these doctors fit the profile of the psychopath salesperson.

    Steve Lucas

    January 17, 2014 | 3:41 PM

    When the President of this country engages in frank cronyism and has people with profound conflicts of interest allegedly investigating matters of criminality and either not investigating or arriving at quick or disgustingly delayed conclusions claiming no wrongs were committed, well…

    It comes back to my several posts at my blog titled “why do people tolerate incompetence, irresponsibility, and criminality.”

    People depend on apathy indifference and silence.

    Keep up the good work, APA members!!!!

    Brett Deacon
    January 17, 2014 | 11:34 PM

    Amen, Joel! I couldn’t agree more. No doubt you made this same point, but far more vociferously, when G. W. Bush was president. Presumably, for the sake of consistency, you called for prosecutions of the war criminals in the Bush administration whose “incompetence, irresponsibility, and criminality” breathtakingly exceeds anything that has occurred in the Obama administration. Right? I’d hate to think you’re using this discussion about psychiatry to score political points. (awkward transition)….back to the APA….

    January 19, 2014 | 1:43 PM

    This scandal simply illustrates that the movers and shakers at APA don’t take the DSM-5 seriously and couldn’t care less what’s in it. It’s just something to sell to raise money for continued operations and boondoggles.

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