1 Boring Old Man

A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists

PLoS Medicine

by Lisa Cosgrove and Sheldon Krimsky

March 13, 2012

Summary Points

• The American Psychiatric Association (APA) instituted a financial conflict of interest disclosure policy for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
• The new disclosure policy has not been accompanied by a reduction in the financial conflicts of interest of DSM panel members.
• Transparency alone cannot mitigate the potential for bias and is an insufficient solution for protecting the integrity of the revision process.
• Gaps in APA’s disclosure policy are identified and recommendations for more stringent safeguards are offered.

At the time, I made this chart to illustrate their reported findings:

Then APA President John Oldham issued an immediate Press Release denying the analysis in their paper. Said APA CEO James Scully [lame…]:

In a statement, APA medical director and ceo James Scully says the DSM-5 development process ‘is the most open and transparent of any previous edition of the DSM. We wanted to include a wide variety of scientists and researchers with a range of expertise and viewpoints in the DSM-5 process. Excluding everyone with direct or indirect funding from the industry would unreasonably limit the participation of leading mental health experts in the DSM-5 development process.

The issue on the table at the time was the Task Force plan to eliminate the Bereavement Exclusion from the diagnostic criteria for Major Depressive Disorder. The obvious fear was that this was simply a move to open up the grief market for antidepressants [DSM-5 To The Barricades On Grief, a fundamental flaw…]. Again, APA President Dr. Oldham explained:

"What we know," Dr. Oldham said, "is that any major stress can activate significant depression in people who are at risk for it. It doesn’t make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."

Then in December 2012, the Washington Post had an article about the extensive COI with PHARMA among DSM-5 Task Force and APA Guidelines members [Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes], focusing specifically on the proposed elimination of the Bereavement Exclusion and the possibility of overmedication of normal grief. In that article, APA CEO Scully reiterated:

Each work group member was allowed to receive as much as $10,000 a year in income from pharmaceutical companies and hold as much as $50,000 in stock. Members could also receive unlimited amounts of money from pharmaceutical companies to conduct research. Scully said that if no financial ties were permitted, many knowledgeable psychiatrists would be excluded because so many university studies are funded by pharmaceutical companies.

… The Washington Post article also brought up criticisms about the DSM-5’s removal of the bereavement exclusion from the criteria for major depressive disorder, which would be replaced with cautionary notes for clinicians. But will these notes be enough to help differentiate between normal grieving and a potentially serious problem?

"Yes," Dr. Kupfer told Medscape Medical News. "This change draws clinicians’ attention to the distinctions between grief after a significant loss and depression. The exclusion criteria will be replaced by 2 notations — a footnote at the end of the criteria that cautions clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder, and a note embedded within the criteria that reminds clinicians that major depression and bereavement can coexist." "This provides greater guidance to clinicians to help make this distinction and ensures that it is understood that sadness, grief, and bereavement are not things that have a time limitation to them, as dictated in DSM-IV’s bereavement exclusion," he said.

He noted in the release that removing the exclusion "helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment, including therapy or other interventions."

Yet Another Ruse by Pharma to Muddle Conflict-of-Interest Rules

Family Dysfunction and Mental Health Blog

by David M. Allen MD

January 10, 2013

[full text on-line]

… David Kupfer, MD, chair of the DSM-5 Task Force, said in a news release"While speculation is bound to occur, we think it is important to stay focused on the fact that APA has gone to great lengths to ensure that DSM-5 and APA’s clinical practice guidelines are free from bias."

In his news release, in which he defended the policies regarding conflict of interest in the members of the different groups that were working on the DSM -5, published in the Psychiatric Times, he stated“… all individuals agreed that, starting in 2007 and continuing for the duration of each individual member’s work on DSM-5, that individual’s total annual income derived from industry sources [excluding unrestricted research grants] [italics mine] would not exceed $10,000 in any calendar year, and he or she would not hold stock or shares of a pharmaceutical or device company valued at more than $50,000."

So nothing to worry about?  No conflict of interest here? Unfortunately, that part I highlighted in the above quote is big enough to drive the proverbial truck through. As the article in the Washington Post of 12/26/12, pointed out, “Members [of the various task forces creating the new DSM] could also receive unlimited amounts of money from pharmaceutical companies to conduct research.”

If the drug companies are supporting the research of an "expert," how is that not financial influence?  Most of these experts are academics; if they do not get funding, they often cannot keep their jobs! Depending on Pharma for your income is hazardous to your objectivity. This very sly loophole in disclosure and conflict-of-interest rules has also been exploited by some Pharma-funded researchers who label themselves as “unpaid consultants” in the “disclosures” attached to journal articles…

and more…