David J. Kupfer, MD and Darrel A. Regier, MD, MPH
Drs Cosgrove and Bursztajn are critical of COI policies for individuals involved in the development of DSM-V. We share the desire for a transparent process and an unbiased DSM-V. Our goal is an evidence-based DSM-V manual that is useful to clinicians and patients.
However, in alleging bias in this process, Drs Cosgrove and Bursztajn reflect biases of their own that should not go unchallenged.
The first is the assumption that something has been proved to be wrong, or will be proved to be wrong, about financial relationships between the APA and the pharmaceutical industry. Sen Grassley requested financial data related to these relationships from a number of medical specialty societies, including the APA. There was no accusation of wrongdoing. The APA responded fully to the senator’s request and has received no feedback from him. The pharmaceutical industry contributes no funds for the development of DSM-V. In fact, most APA revenue received from the pharmaceutical industry is for advertising in journals or newsletters such as Psychiatric News. Many publications, including Psychiatric Times, receive significant advertising revenue without any assumption of bias.
Second, the authors claim that the public has lost trust in DSM because pharmaceutical industry ties of members of the DSM-IV Task Force in the late 1980s and early 1990s inappropriately influenced the validity of the diagnostic criteria. In an earlier article by Dr Cosgrove,3 she and her colleagues retrospectively investigated disclosures made by DSM-IV Task Force members after the publication of DSM-IV—such as industry support for research, consultations, or CME presentations. Without offering any supporting evidence, the authors then asserted that such links prove that the reputation of DSM-IV was damaged. This is a classic “guilt by association” logical and ethical fallacy.
Third, the authors assume that the public sees all connections between academic psychiatry and the pharmaceutical industry as inappropriate. They seem not to appreciate or understand how the collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders.
The pharmaceutical industry operates in a highly competitive market, but it is also a regulated industry that has seen changes in the regulatory processes to address emerging problems. However, for those whose ideological beliefs about mental disorders do not include a role for medication and who reduce the emergence of explicit diagnostic criteria with DSM-III to nothing more than a checklist “that allows pharmaceutical companies to bring ‘me-too’ drugs to market,” there is little possibility that any change in DSM-V will be satisfactory.
The authors lament “the relative neglect of psychodynamically in-formed narrative descriptions in DSM.” Although the hope was that research could test and confirm the value of these descriptions, the authors’ references to their own publications on the efficacy of psychodynamic treatment are not comparable to the massive evidence for the efficacy of other psychotherapies, such as CBT and IPT, and pharmacological treatments that have been facilitated by the DSM framework.6,7
In the recommendations section of their letter, the authors start with the unproven assertion that the APA and DSM have lost credibility and the mistaken assumption that the public disclosure of members of the DSM-V Task Force was an attempt to restore credibility. The authors failed to recognize that at the time DSM-IV was developed in the late 1980s and early 1990s, there was no policy for public disclosure of financial interests in any journal, publication, or annual meeting—all of these policy changes occurred after 1994. The disclosure policy for DSM-V follows current disclosure standards, with added limitations developed by the APA Board of Trustees on the total amount of industry funding that a participant can receive. Public posting of the members’ disclosures was a voluntary effort by the APA to demonstrate its commitment to and agreement with the need to limit potential industry bias in the development of DSM-V.
Given the authors’ now well-documented antimedication and anti-industry bias, it is clear that they would prefer to have no one on the DSM-V Task Force or Work Groups with any connection to industry. However, we believe that careful attention to potential conflicts of interest, including those of individuals committed to a single school of psychotherapeutic intervention or approach, will inform diagnostic revisions with a broad scientific base that has been greatly enlarged and facilitated by the definitions of mental disorders provided since the release of DSM-III. This includes geneticists who are looking closely at the future feasibility of having genetically informed, specific pharmacological treatments for treatment-resistant depression in the same manner that such genetically informed pharmacological treatments are now available for certain forms of breast cancer. In one of their references, the authors note approvingly of our published interest in considering more dimensional, developmental, and culturally sensitive expressions of mental disorders in DSM-V.7
We invite Drs Cosgrove and Bursztajn and the readers of Psychiatric Times to monitor the most inclusive and transparent developmental process in the 60-year history of DSM at our Web site—and to submit any additional recommendations for the process or content of this collaborative scientific effort.