DSM-V’s Conflicts of Interest

Earlier this week, the Boston Globe’s health blog dived into the issue of conflicts of interest for the latest mental disorder diagnostic manual being formulated. The diagnostic manual is known as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and a fifth version of it is currently in development.

How a disorder makes it into the DSM — which is used by mental health professionals and insurance companies to legitimize and pay for a mental health concern — has been the subject of numerous research papers and essays. It is a messy process, like sausage-making, and involves a combination of expert testimony (often given by the same experts who lead a subcommittee on the specific disorder), research on the disorder, and, of course, a healthy dollop of politics. Disorders do not make it into the DSM based solely upon the empirical evidence.

As the Globe’s health blog reported, 16 of the 28 members of a task force overseeing revision of the DSM have disclosed financial ties to drug or medical device companies, according to the Center for Science in the Public Interest. This naturally raises some concern about possible conflicts of interest.

The American Psychiatric Association, publisher of the DSM, responded to the Globe by saying,

“We have made every effort to ensure that [the manual] will be based on the best and latest scientific research, and to eliminate conflicts of interest in its development,” Carolyn B. Robinowitz, president of the psychiatric association, said in a statement.

The number of professionals with pharmaceutical industry ties has risen 14% from the last revision:

Lisa Cosgrove, a clinical psychologist at University of Massachusetts-Boston, who helped write a 2006 paper exposing conflicts of interest in the last edition of the manual, said the new task force has 14 percent more members with industry ties than the one working on the 1994 version.

“When I did that study, it was not an attempt to ban people with financial ties,” she said in an interview. “I think a more balanced and realistic approach would be to actively recruit critics of industry-funded research as opposed to an outright ban.”

I think the Globe’s reporting missed the mark about this issue on two counts — conflicts of interest and relevance of such conflicts to the task at hand.

What the article didn’t really underline was that (a) the DSM committees have always had members with conflicts of interest and (b) that these conflicts of interest go well beyond ties to pharmaceutical companies. Remember, many of the experts chosen to sit on these committees are the same professionals who have made their livelihood studying these disorders.

An expert on depression, therefore, has her entire professional career (a pretty big conflict of interest) invested in ensuring that the depression diagnostic category is not only represented, but expanded. After all, experts regularly believe their area of expertise is under-appreciated and under-represented. The same thing is true with experts representing new disorders under consideration for inclusion in the new revision. You won’t find many naysayers on such committees.

But these kinds of conflicts aren’t directly disclosed — one has to research each member’s background to see how dependent their career is on ensuring the growth and expansion of each disorder. Nobody’s career is going anywhere if the disorder they’ve dedicated their life to researching is suddenly downsized or kicked out the DSM altogether.

So by its very nature, the DSM emphasizes growth of mental disorders, and the APA naturally seeks out experts who will help it achieve that goal. With the explosive growth of psychiatric drug treatments since 1994, it’s not surprising that the number of experts with pharmaceutical ties also has grown.

The second problem is linking conflicts of interest to the possible negative outcomes of such conflicts.

I believe the impact of these kinds of conflicts of interest for the DSM are fairly limited, because the DSM is a diagnostic manual, not a treatment manual (it has absolutely zero references to treatment or treatment strategies for a disorder). This was done on purpose (because there is such disagreement amongst professionals about what constitutes proper and appropriate care for nearly all mental disorders).

Committees are held to their decisions by the record of their discussions and decisions made. Nowadays, such decisions have to fall largely within the line of the current research trends. Anything that is an outlier from such trends is going to be significant and noticed when the DSM-V is published.

So while I’m disappointed to see the pharmaceutical industry influence in the DSM-V, I think it was inevitable without an outright ban by the APA on such professionals participating. And such a ban is impossible, because most professionals (and certainly most experts within any given area) take pharmaceutical funding in one form or another because it is so prevalent, widely available, and accepted within the profession.

Does that make it right or the best possible choice? No, and the APA would do well to hear the concerns of many of its own members, consumers and the media in making changes to this policy for the inevitable DSM-V revision process, as well as future versions of the DSM in the decades to come.