why? again…

Posted on Sunday 19 January 2014

in this post, the footnotes [x] are keyed to the now numbered items in the earlier post when?… to cut down on the ground clutter…

The revelation of a closely held secret like Dr. Kupfer et al’s undeclared Conflict of Interest is like an embarrassing slip of the tongue – its meaning is immediately apparent. After a stammer, the usual first reaction is an attempt at damage control – like their published apology [24] without acknowledging that it was a response to being discovered [22, 25]. The next line of defense is to either deny that the impropriety in question did any harm, or say that it didn’t mean what it seems to mean. In this case, that came in the form of a memo from the Speaker of the Assembly of the APA, Dr. Mindy Young, to the APA Trustees [27]. Says Neuroskeptic [Psychiatrists From Another Dimension (Part 1)]:
Kupfer was actually put up before the APA’s version of a Congressional Committee, the Assembly of the APA, for this. And now, in a letter dated last week, the APA decided that he was wrong to fail to disclose a CoI:
    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…
But the APA went on to say that the DSM-5′s dimensional turn was not influenced by commercial interests:
    Use of dimensional measures dates back to the 1960s… from 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.
Such is the APA’s retrospective. They then turn their hand to fortune-telling, and predict that
    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.
I would be less forgiving here. There’s no grounding for either the fortune-telling or the predicting. Besides the obvious breach of ethics and integrity, this is the central problem with an undeclared Conflict of Interest. Its impact is impossible to evaluate when it’s revealed after the fact. Dr. Young has no basis for saying that their planned commercial enterprise had no impact on the DSM-5’s preoccupation with dimensional measures or that the NIMH funded, DSM-5 Chairman endorsed, CAT has no leg up on its competitors. In either case, these are her speculations. The APA she represents has a huge Conflict of Interest in that the now published DSM-5 is the cash cow extraordinaire in a time of famine as well as an important symbol. I would be in the same position if I said the opposite. Neither position can ever leave the realm of speculation. That’s why we insist on a priori declarations of Conflicts of Interest – a standard known and supported by Dr. Kupfer himself. He well knows the power of an accusation of Conflict of Interest, having exerted it himself in the initial response to Dr. Carroll’s criticism  [19] and in his response to Dr. Allen Frances in 2009 [Setting the Record Straight: A Response to Frances Commentary on DSM-V]. Speaking of setting the record straight, there are several points in Dr. Young’s letter [27] that deserve a response:

  • "The stock interest in PAI did not influence DSM-5’s move toward dimensional measures."
    That’s backwards for one thing. The allegation is that the company was capitalizing on the DSM-5’s move towards dimensional measures and may have, in turn, fueled some of that advocacy.
  • "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."
    In the time frame she’s discussing, there were no publications about the CAT-anything. The first one came a month before the Trustee’s final approval [13]. If the CAT was not considered viable, that means that it was considered, ergo it had to have been brought up to the the DSM-5 Instrument Study Group for consideratio.
  • "… 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."
    … in response to Dr. Kupfer’s continuous strong advocacy of the dimensional measures [1, 3, 4].
  • "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."
    But by virtue of being developed by the NIMH, by being advertised in major peer-reviewed journals in academic articles, and by having the Chair of the DSM-5 Task Force behind it, it has an enormous competitive advantage.
  • "Drs. Gibbons, Frank and Kupfer disclosed their interest in PAI publicly in AJP before disclosing it in JAMA Psychiatry."
    The disclosure in a submitted but unpublished article prior to incorporation is a forced argument. They didn’t tell us about it. It’s an off-point legalistic argument.
Those are just a few of the arguments about parts of the letter, but they’re included only to say that the letter feels like the closing argument for a defense lawyer, not a thoughtful exploration of the obvious important issues engendered here. Surely this is not intended to be the APA’s final review of this affair. The Board of Trustees has both a need and an obligation to investigate with an unbiased panel. Their decision here will be a much needed precedent for future issues involving Conflicts of Interest in the APA. Likewise, the NIMH has a similar obligation to look into the use of NIMH Grant money to develop this commercial product. Is it even the author’s product to sell? And what about Dr. Gibbons’ current project? Is he doing it again [what!…]?

In medical school, we’re taught to begin every part of a physical exam with inspection. Look at the ear before poking in an otoscope. Look at the chest and breathing before listening with a stethoscope. And that’s good advice about looking at this timeline before getting lost in its details. Every article from the first one in 1993 to the most recent one reads like these tests are designed as commercial products [1, 6, 13, 20, 21]. They’re not better psychometrics. The question is still out on whether they’re as good as [I think Neuroskeptic plans to weigh in on that in his (Part 2)]. But they are quicker and easier. Dr. Kupfer’s enthusiasm for dimensional measurements pervades his commentaries [3, 4, 15, 16]. In Dr. Costello’s resignation, she quotes him as saying, "Thus, we have decided that one if not the major difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V" [7]. He was still at it when the DSM-5 was released [Section III of New Manual Looks to Future]. And if there’s any question about the link between the CAT tests and dimensional measurement, read the PsycsTalk article [23 click page 4]. While there may have been a disclosure in a file drawer at the AJP and an April 2013 disclosure in some APA office, there was no public disclosure of a Conflict of Interest until after they knew of Dr, Carroll’s letter to JAMA Psychiatry [22], after the DSM-5 was in print. And there were several places where it could’ve should’ve been mentioned [15, 16, 19].

And of course the biggest question of all is why?…, why all the secrecy? It’s the one Dr. Young avoids. And it’s the one I started with, and I still think is the most important thing on the table…
    Brett Deacon
    January 19, 2014 | 9:01 PM

    Great post Mickey, and I share your concerns. I learned a few years ago that NIMH had given $1 million to researchers affiliated with the University of Washington to construct a high-quality, interactive, web-based therapist training program on exposure therapy for anxiety (http://behavioraltech.org/ol/details_exp.cfm). I’ve done the training and it is absolutely fantastic. The training program is not freely available to the public – it costs $249 for 4 months access, $349 for 12 months. All the proceeds go to Behavioral Tech, LLC. I mention this in the service of noting that NIMH is in the business of spending taxpayer dollars to enrich private companies. A questionable practice, indeed.

    January 20, 2014 | 7:22 PM

    That we let companies test their own products for FDA approval is bonkers, but it has been normalized. That the companies are subsidized by the government is just as normal. Most citizens don’t see that as corporate welfare or a conflict of interest, they see it as “free market” booster-ism and believe that private business is always more efficient, productive, and disciplined than government agencies. Most people would be quicker to blame the FDA than the corporations that manufacture ‘life-giving’ medication.

    Psychiatry isn’t alone in its corruption by neo-liberal economic policies. Other medical industries, however, do not have the power to determine who is and is not sane, to write off minds and personalities as being hopelessly sick without medication even though most mental health professionals don’t even begin to know and understand the people they treat. Yet, they have the power to manipulate the courts according to their postulates they parade around as scientific theory in order to take over some person’s life and confine them with very little forethought, at times. An oncologist isn’t going to have a patient’s children taken away from her because of a diagnosis, for instance, and won’t label a patient as always being chronically cancer-ridden for life and in need of non-stop medication for cancer whether it’s in remission or not.

    There’s no groundswell of public support for radical changes in the status quo. There is no groundswell of professional support or radical changes in the status quo; but a movement is beginning.

    The DOJ is busting doctors and medical institutions for MEDICAID fraud in no uncertain terms. Professional psychiatrists are challenging the fraud and bad science in the field. Neurologists are being responsibly critical of the unbridled enthusiasm and sloppiness of imaging in search of physical causes of “mental illnesses”. Academics are working toward open-source studies for transparency and the more rapid advancement of the sciences. Patients are advocating for better. Alternatives that have proven effective are being talked about and seriously considered. The federal government and states are suing drug manufacturers for larger and larger sums for false advertising and lying about the effectiveness and safety of many drugs.

    And then there are the issues of HMOs and insurance companies.

    This mind-bending mess has been forty years in the making— and will likely be taken down much quicker— but it’s got to be hammered on all sides. Also, something solid needs to be put into place to handle the problems that the floridly psychotic, overwhelmed, and suicidal have always had with as much care and time as is required to stabilize those who can’t take care of themselves.

    Hopefully, open minds and cool heads will prevail— those with the knowledge and experience to address the complexity in terms most people can understand, and who are capable (like Dr. Nardo) of understanding these issues in both humanistic and scientific terms with an understanding of statistics and heuristics.

    Throwing the baby out with the bathwater could be as damaging to the most needy as the industry doubling down with biological determinism in the face of evidence to the contrary is to people who are suffering from social ills and blaming themselves for not rising above powers that are much bigger than they are. It will take careful thought and precise speech to effectively counter all that is fubar about psychiatry.

    It’s so comforting to have met people online who are on the forefront of the push toward better model for the care of overwhelming mental/emotional distress, who are humble, fair, and attentive. Thanks.

    Personally, I think I’m just about over psychiatry, but will check in from time to time to see how the big picture is looking from the perspectives of you, Mickey and other mental health professionals and advocates linked to here, and those who comment here.

    Rah sis boom! I cheer you on.

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