{"id":42797,"date":"2014-01-03T11:30:27","date_gmt":"2014-01-03T16:30:27","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=42797"},"modified":"2014-01-03T16:04:06","modified_gmt":"2014-01-03T21:04:06","slug":"dsm-5-retrospective-ii","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/01\/03\/dsm-5-retrospective-ii\/","title":{"rendered":"DSM-5 retrospective II…"},"content":{"rendered":"
In DSM-5 retrospective I…<\/a> I reviewed some of the story of the DSM-5 beginning with Kupfer et al’s 2002 book, A Research Agenda for the DSM-V<\/a> [I continue to think that one can’t understand the DSM-5 without reading, or at least scanning that book – it’s a free pdf<\/em>]. I thought it was a trick to rationalize changing rather than revising the diagnostic manual, and saw it and the process that followed as heavily influenced by commercial interests. Before I read it, all I knew of Dr. Kupfer was from ancient history. He was a major figure in the search for biomarkers back then, and he found one:<\/div>\n
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REM latency: a psychobiologic marker for primary depressive disease.<\/a><\/div>\n
by Kupfer DJ.<\/div>\n
Biological Psychiatry<\/font><\/strong>. 1976 Apr;11(2):159-174.<\/div>\n

<\/p>\n

Previous investigations have indicated that one of the most consistent EEG sleep findings in depressive patients has been a shortened REM latency. On the basis of these studies, we have concluded that with the exception of drug withdrawal states [such as CNS depressant or amphetamine withdrawal and narcolepsy] shortened REM latency points to a strong affective component in the patient’s illness. Short REM latency has also been observed in patients suffering from schizo-affective illness as well as in certain schizophrenic patients who require tricyclic antidepressants in their management. Furthermore, this psychobiologic marker is a persistent, rather than a transient phenomenon, and can be observed over a period of several weeks unless a patient’s condition becomes more favorable through clinical intervention. This present report indicates that short REM latency is found in virtually all primary depressive illness and is absent in secondary depression. Thus, REM latency appears to be a dependable, measurable marker for diagnosing primary depression, and we argue that the phenomenon is independent of age, drug effect and changes in other sleep parameters. It is expected that EEG sleep and motor measurements can yield further significant data and improve differential diagnosis in psychiatry, in much the same way that laboratory data support other medical specialities.<\/div>\n<\/blockquote>\n
It’s a heavily  cited paper in the Biological Psychiatry<\/em> journal. I recall it as one of the important moments along with Dr. Carroll’s Dexamethosone Suppression Test that seemed to be  a window opening into the biology of Endogenous Depression. But after 1980, there was no more Endogenous Depression to study, and its analog, Melancholia, moved from its time honored place as a noun, to an adjective tacked onto something else, Major Depressive Disorder. Their sensitivity was not high enough to gain them wide acceptance as clinical tools, but the implication of biological correlation were certainly widely noted and discussed.<\/div>\n

But this was a different Dr. Kupfer on a different trajectory. Then recently, we happened on to another story [see insider trading…<\/a>]. This Dr. Kupfer was a coauthor and business partner with statistician Robert Gibbons in developing a computerized screening instrument for depression and anxiety. It was developed using NIMH grants by Dr. Gibbons. It was discussed in a series of papers in our best journals. But it was not mentioned as a conflict of interest by any of the authors even though it turned out to be a mature commercial enterprise waiting to launch. Only after it was exposed did the authors offer an apology for failing to list it as a COI. but offered no explanation. To make things remarkably worse, this screening test aims to capitalize on a part of the DSM-5 present from inception – Dimensional Diagnosis [as in anxiety and depression] – a part of the DSM-5 specifically championed by Dr. Kupfer from the outset. This isn’t just the appearance of a COI. This is<\/u> a COI. This is the kind of thing you can go to prison for in the dog-eat-dog business world. And Medicine should and does have a higher standard than that.<\/p>\n

Lest you think this connection between Dr. Kupfer and Gibbons company and the DSM-5 is just circumstantial evidence, try this on for size. Today, I was pointed to something else. This is from Dr. Jane Costello<\/a>‘s letter of resignation from the DSM-5 Task Force in 2009 [reproduced here from the Carlat blog<\/a>]:<\/p>\n

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The tipping point for me was the memo from David and Darrell on February 18, 2009, stating “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”, and going on to introduce an Instrument Assessment Study Group that will advise workgroups on the choice of old scale measures or the creation of new ones. Setting aside the question of who “decided”, on what grounds, anyone with any experience of instrument development knows that what they proposed last month is a huge task, and a very expensive one. The possibility of doing a psychometrically careful and responsible job given the time and resources available is remote, while to do anything less is irresponsible…<\/div>\n
hat tip to Uri<\/strong>… <\/div>\n<\/blockquote>\n
I have a worst case impression of what went on here. After his REM sleep days, Dr. Kupfer became a member of the KOL Klan. Like many of his colleagues, his name is on 900+ papers<\/a>, including a few<\/a> with Dr. Gibbons who was a consultant to the DSM-5<\/a> Task Force on the very Diagnostic Assessment Instruments Study Group<\/font><\/strong> mentioned above by Dr. Costello. Kupfer began to lead the DSM-5 Task Force with the agenda of making the change to a neuroscience based document with psychiatry becoming a neuroscience based specialty. In 2002, he was in solid company. It was before the scandals and disillusionment with the pharmaceutical academic alliance in psychiatry. It appears as though he and Dr. Gibbons saw a way to capitalize on the "diagnosis by dimension" theme, and Dr. Gibbons got $5 M from the NIMH to develop his instrument [really?…<\/a>]. Maybe they had independent plans that ran together later. But however this came about, they never declared their commercial plans as a COI for obvious reasons – it was too incriminating<\/em>. As I said, this was insider trading…<\/a><\/div>\n

And what about "the memo from David and Darrell on February 18, 2009, stating ‘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’, and going on to introduce an Instrument Assessment Study Group that will advise workgroups on the choice of old scale measures or the creation of new ones.<\/em>" I presume from this that in 2009, they still fantacized adding Dimensions to the DSM-5, quantified by psychometrics. That was certainly apparent in their symposium, Dimensional Aspects of Psychiatric Diagnosis<\/a>, in 2006.<\/p>\n

So what’s to be made of all this?<\/div>\n
    <\/p>\n
  • \n
    The secret development of the CAT-DI and CAT-ANX instruments on NIMH money as a commercial enterprise by members of the DSM-5 Task Force targeting the Dimensional aspect of the DSM-5 being championed by Dr. Kupfer, a share holder, is a scandal of the first magnitude. It was a very unethical thing to do. They lied outright to do it. And the potential for the test to be used to increase the burden over-medication to the detriment of our patients makes it an even more cynical endeavor. In a rational world, the American Psychiatric Association should be investigating this story with an eye on censoring everyone involved.<\/div>\n<\/li>\n
  • \n
    The scandal is part of a larger push to radically change the psychiatric diagnostic system to fit the vision of a sub-segment of the psychiatric hierarchy, undertaken largely behind closed doors, following an agenda that was never made explicit or validated by the general psychiatric community. The plan was to make psychiatry conform to their neuroscience and psychopharmacologic models, heavily influenced by commercial and industrial interests. That initiative consumed the efforts of the DSM-5 Task Force. And it failed.<\/div>\n<\/li>\n
  • \n
    The $25 M DSM-5 Task Force spent its time and resources trying to put the agenda mentioned in 2. into place unsuccessfully, and ignored their assigned task. There were plenty of major glitches in the DSM-IV that needed attention like the Major Depressive Disorder diagnosis that were ignored, and were perpetuated in the DSM-5. So we let the Mental Health community at large down as well as psychiatry and our patients by focusing on the agenda of a circumscribed subgroup of psychiatrists, many of whom were compromised by obvious conflicts of interest.<\/div>\n<\/li>\n

    <\/span><\/ul>\n

    I wish I could say otherwise, but this recent revelation about Dr. Kupfer’s folly and the failure of the DSM-5 in general is just one more example of corruption in high places for personal gain in psychiatry – epidemic in the KOL culture that has dominated the field for several decades. And the overall story of the DSM-5 Task Force is a tale of the influence of industry being put into policy by this same strata of our academic community.<\/div>\n","protected":false},"excerpt":{"rendered":"

    In DSM-5 retrospective I… I reviewed some of the story of the DSM-5 beginning with Kupfer et al’s 2002 book, A Research Agenda for the DSM-V [I continue to think that one can’t understand the DSM-5 without reading, or at least scanning that book – it’s a free pdf]. I thought it was a trick […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-42797","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42797","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=42797"}],"version-history":[{"count":18,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42797\/revisions"}],"predecessor-version":[{"id":42849,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/42797\/revisions\/42849"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=42797"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=42797"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=42797"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}