under this rug…

Posted on Friday 28 March 2014

"My contacts tell me that a reliable source on the APA Board of Trustees informed members that the APA attorney has declared that there was no conflict of interest, effectively preempting any action by the Assembly."
Bernard Carroll – comment on not a peep…

I think it is likely true that the APA attorney declared that there was no conflict of interest in Dr. Kupfer’s actions detailed previously. While it’s hard to imagine what legal machinations the Attorney went through to come up with such an absurd conclusion, I’ve had my say about that multiple times. So for the moment, I want to talk about something else. Is a legal standard even appropriate to bring up in this case? We’re not talking about a person charged with a criminal offense going to trial or a civil suit alleging damages of one kind or another. And even in those situations, the opinion of a legal adviser isn’t the final word, it is only an opinion. Those verdicts comes from a Judge or a Jury.

In this case, the person under question is a high ranking official of the American Psychiatric Association tasked by the Board of Trustees to oversee a $25 M revision of the APA’s Diagnostic and Statistical Manual, a process over a decade in the making. The question is by what standard should such a person be judged. In the many debates about conflicts of interest over the life of the DSM-5 Revision process, the topic invariably revolved around the ties between DSM-5 Task Force members and the pharmaceutical industry – for example this pointcounterpoint debate in the Psychiatric Times in 2009 involving Dr. Kupfer. The idea that a leader of the DSM-5 Task Force would be part of founding a company that produced screening instruments for things he was also supporting for inclusion in the manual never occurred to anyone. It was too outlandish to consider. But that’s what he did. And in an article about those tests in a peer reviewed journal, he omitted the required disclosure.

I presume that if we had the APA’s lawyer’s opinion, it would be something like: although the company was named, formed, incorporated in two states, professionally managed, and had a website, it had not yet officially launched its products, so technically that meant it wasn’t a conflict of interest. Something like that. That kind of technicality is well known to us from 20/20, or Mafia cases. This isn’t about such things. This is about medical ethics and integrity. And it’s not some Monica Lowensky dalliance – it’s in the direct line of duty. I can’t personally find a way to read this story as anything but profiteering. I gasped when I first heard it. Apparently the editor of JAMAPsychiatry did too, measured by the form of the published apology [Failure to Report Financial Disclosure Information]. I expect the members of the Board of Trustees at the APA gasped too [at least I hope so]. This wasn’t an ethical lapse. It was an active attempt to get away with something that went awry. No need to look at any rules to know that. Even if they had waited to incorporate their company until after the DSM-5 came out, or Kupfer had declared it along the way, it was still a misuse of his position for personal gain. There’s no piece of this caper that isn’t conduct unbecoming the chair of such an enterprise.

All of that is obvious. If it is indeed true that "the APA attorney has declared that there was no conflict of interest, effectively preempting any action by the Assembly," that does not mean that the APA Board of Trustees must remain silent, because that silence screams indifference or worse. They may be afraid of getting sued for slander by Dr. Kupfer, but they need to be even more frightened of their silence putting the finishing touches on the demise of an already heavily tarnished ethical reputation. They have to speak. There’s just no more room under this rug…
    March 28, 2014 | 8:30 PM

    Seemingly off topic, but not really so: The Governor of New Jersey, Chris Christie, was just “cleared” of any wrongdoing in a legal opinion offered by a law firm he retained, albeit at tax payer expense, to investigate his possible role in the lane closures at the George Washington Bridge this past summer. The opinion offered by these hired guns and legal eagles essentially took a sexist route, and said Christie’s political staff member, a woman, was “emotional” and “irrational” and ordered the lane closures because a boyfriend dumped her. Amazing.

    I guess the point is that any individual or organization can hire an attorney to give a whitewash to any wrongdoing. And I think that’s what APA did in regard to Kupfer.

    March 28, 2014 | 9:23 PM

    I was thinking white collar crime akin to insider trading, which I think is correct enough, but the purpose of committing this crime is profiteering— good term. That it tries to dress itself up as helping psychiatrists help more patients by reducing them to an algorithm more efficiently, it’s dehumanization.

    donald klein
    March 28, 2014 | 11:21 PM

    The issues about Dr. Kupfer ,DSM-5 ,COI , simple profiteering and the irrelevance of legal standards to a decision of effective malpractice ,elicit strong emotions. However,it beclouds the issues to argue that an attempt to systematize diagnosis and outcome prediction amounts to that buzz word ,”dehumanization”. If it is an approach that fails or misleads , there are adequate ,but expensive, techniques for determining this. The FDA could see that these mechanized approaches fall within the range of medical devices–or if the current law does not fit–there is an opportunity for the science concerned organizations to demand good practices–but not to befog the issues by such emotionally loaded pejoratives–such as “dehumanization”‘ which so easily spread away from the factual issues.

    Bernard Carroll
    March 28, 2014 | 11:45 PM

    Here is more food for thought on the topic of impeachment rather than criminal pursuit. That is the point Mickey is getting at. And if the Board members don’t bestir themselves, people will be talking about more than Dr. Kupfer’s impeachment… it will spread to the likes of Dr. Jeffrey Lieberman and the Board of Trustees.


    March 29, 2014 | 1:24 AM

    Again, who of integrity and responsibility to public trust belongs to the APA?

    berit bryn-jensen
    March 29, 2014 | 5:45 AM

    Everything legal is not right.
    Everything right is not legal.

    Quote from a lecture on medical ethics at the University of Oslo, by a young doctor of medicine..

    March 29, 2014 | 3:04 PM

    “Conduct unbecoming” depends on whose eyes are viewing the conduct. We think Dr. Kupfer’s conduct is unbecoming, but his peers at the APA don’t think it’s ugly at all. They’re probably double-dipping as much as they can themselves.

    And what’s wrong with double-dipping? Who is being harmed? In the Kupfer, case, the world has a new DSM-5 to aid diagnosis and treatment of the dread scourge of mental illness that’s swamping civilized society and, if everything goes right, there will be a new multiple-choice questionnaire to pigeon-hole patients in the minimum amount of time. Everybody wins!

    Is Kupfer a liar? As Dr. Mickey noted, this will depend on the fine parsing of a word or a phrase. Did he have interests in a conflicting “enterprise” or a “product”? Debatable.

    You see, when you subtract the issue of patient harm from these ethical kerfuffles, they evaporate. Since nobody wants to acknowledge the elephant in the room, these COI disputes amount to nothing but personal definitions of proper etiquette.

    (In my personal opinion, those psychological questionnaires are all dehumanizing. This is not hyperbole, complex life situations are reduced to a score on a multiple-choice test. You can’t get more dehumanizing than that.)

    Bernard Carroll
    March 29, 2014 | 4:48 PM

    I agree with Don Klein’s comments above, and I take issue with Alto’s position. There is an important place for psychometrics. I have been a psychometrician for 50 years since I came up with my depression scale. To call clinical symptom scales dehumanizing is no more valid than to call psychiatric medications dehumanizing. Both positions are way too extreme. The essence of clinical work is to recognize underlying disease structures in the unstructured narratives of complex life situations. Clinical symptom scales can help us do that, and they are especially useful for following the progress of patients with established diagnoses, not to mention their utility as a common language in research studies.

    My psychometric objection to the new scales of Dr. Kupfer and his group is that they are not clinically grounded, they dumb down and trivialize the clinician-patient interaction, they are motivated by a misplaced overemphasis on “efficiency,” and they give undue weight to the test score – like entering it directly from the computer, along with diagnostic implications, into the patient’s electronic medical record.

    March 29, 2014 | 5:27 PM

    Having been on the receiving end of “psychometrics” myself, I call them unqualifiedly dehumanizing. What their proper use might be, I don’t know. In my case, I took them only under voiced protest — and that was at UCSF Psychiatry here in San Francisco. Thus, my Paxil withdrawal syndrome was measured with depression scales, and that’s what went into my medical record. What does that mean?

    Dr. Carroll, if you’re saying a good clinician uses psychometrics properly, we’re back to the tautology that a good doctor is a good doctor. My response to that is: Very true, but a good doctor is hard to find, where does that leave psychometrics?

    As for psychiatric drugs — same tautology, same defects.

    March 29, 2014 | 5:29 PM
    Bernard Carroll
    March 29, 2014 | 5:53 PM

    Oh, there are lots of proper uses of psychometrics. If your case was mismanaged then I am sad for you but many patients do benefit from psychometric scales. The error in your case seems to have been a function of your particular doctor, not a function of the scales per se.

    March 29, 2014 | 7:40 PM

    Bernard Carroll,

    I’ve seen psychometric scales used to rate the severity of a condition, yet are they used in common practice to exclude a condition?

    Dr. Nardo,

    If none of the parties are held accountable, if not by the law then by the APA membership, why should they worry about their ethical reputation? No harm, no foul, and everyone forgets it ever happened.

    Bernard Carroll
    March 29, 2014 | 9:16 PM

    Arby, yes. Take the context of screening for depression in general medical settings. With the anxiety scale described by Dr. Kupfer and his group, scores below a defined threshold will serve to exclude the diagnosis, and that will be correct at around a 99% level of accuracy. Cases who score above a threshold level will be referred for further assessment. Notice I did not say they will automatically be diagnosed as having a clinical anxiety disorder. That is because the majority of positive screen results – probably over 80% – will be false positives. There can be many reasons for false positive screens, which also occur commonly in medical laboratory testing. So, some rating scales and some laboratory tests are able effectively to rule out but not to definitively rule in a candidate diagnosis.

    Bernard Carroll
    March 29, 2014 | 9:17 PM

    Oops… make that screening for anxiety. Sorry!

    March 29, 2014 | 10:41 PM

    Psychometric scaling is useless unless you have measures of response style— one needs to know if the respondent actually attended to and read the items, responded in a consistent manner, and did so without too much positive or negative impression management.

    March 29, 2014 | 11:12 PM

    This, is the most vindicating, empathetic, respectful and trusting thing I’ve seen coming from the field in the last thirty years:


    March 30, 2014 | 10:43 AM

    Back to the issue of ethical violations. If the APA didn’t think Dr. Kupfer did anything wrong, why would they call in a lawyer to “prove” it?

    March 30, 2014 | 1:24 PM

    “…why would they call in a lawyer to “prove” it?”

    What concerns me is that I don’t believe they think he did anything wrong. Lawyers are for CYA and damage control.

    But, I am open to being proved wrong.

    March 30, 2014 | 1:45 PM


    Please don’t read sarcasm into my answer. It wasn’t meant to be there and I would have used the /sarc tag if it was.

    You asked an honest question and I gave you a sincere answer. One that I am willing to change if I see evidence to the contrary. Of course, my opinion doesn’t matter either way; this is happening in your world not mine.

    March 30, 2014 | 1:53 PM

    Dr. Carroll, having every single prospective patient take a psychometic test is a requirement at UCSF Psychiatry. They won’t see you without one. By UCSF’s lights, my case was not mismanaged. I received the same lousy care everyone does there.

    The problem is institutional. I have to object strongly to the “rotten apple” argument being applied to a widespread pattern of bad clinical practice. This isn’t an occasional error, it’s the norm. The only difference in my case is I’m calling them on it.

    And that is how psychometrics — a theoretically helpful device — is used in the real world. Now, you might argue the abuses are operator error rather than the fault of the instrument. And you might argue guns don’t kill people, people kill people. Yes, inanimate objects are harmless until they are set in motion by humans.

    That psychometic scale over there is not dehumanizing in itself, it’s dehumanizing when applied by a clinician. And not the wrong “rotten apple” clinician, either — the general run of clinicians. Misuse of psychometric scales is a recognized problem in clinical trials.

    Perhaps I should have said the USE of psychometric scales is dehumanizing. In the abstract, psychometic scales are no more dehumanizing than, say, the Enneagram.

    Bernard Carroll
    March 30, 2014 | 2:17 PM

    Alto, what allows you to say everyone at UCSF receives lousy care? Isn’t that being presumptuous? I ask you to give us your basis or take back that smear.

    April 2, 2014 | 4:47 PM

    There was nothing unusual in the care I received, and it was lousy care. If it could happen to me, it could happen to anyone.

    I stand by my statement. The quality of care by UCSF Psychiatry is representative of the quality of psychiatric clinical everywhere. What do you think all of this COI and corrupt research leads to? If you condemn it and compartmentalize it apart from patient harm, you’re missing 90% of the ethical problem.

    Here are more than 1,000 cases illustrating typical problems in psychiatric clinical care, from GPs, individual psychiatrists, university psychiatrists, etc. http://tinyurl.com/3o4k3j5 Note the prevalence of arbitrary polypharmacy and ignorance of adverse effects. This stuff happens ALL THE TIME.

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