Former editors of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have publicly declared their concerns that the ongoing revision process of the influential publication has been cloaked in secrecy. In recent months, debate about the confidentiality agreement that contributors must now sign has been playing out in the pages of the Psychiatric Times. Dr. Allen Frances, editor of DSM-IV, has written several editorials slamming the DSM-V task force for their lack of transparency.
The “real problem now is the almost complete lack of openness about [DSM-V] methods, progress, timelines, and products,” Frances writes in an email.
Dr. Robert Spitzer, editor of DSM-III, has expressed a similar opinion. In 2008, he wrote an open letter criticizing the confidentiality agreement (Psychiatr News 2008; 43:26). In the letter, Spitzer says that he requested the minutes of a DSM-V meeting but was refused. The confidentiality mandate, he wrote, would prohibit the free exchange of information between the DSM task force and outside experts that is essential to effectively revising the manual.
Members of the American Psychiatric Association, which publishes the DSM, have countered these criticisms by claiming the revision process has never been more open. There are more than 150 experts from 16 countries contributing to the manual, the association has noted, and the confidentiality agreement serves primarily to protect intellectual property and to allow task force members to provide input on certain matters without fear of outsiders misinterpreting it or coming to premature conclusions.
“With each version of the DSM that comes out, there is more and more openness in terms of transparency and in terms of making sure that interested parties are kept updated as well as possible,” says Dr. William Narrow, director of the DSM-V task force. “But there is a delicate balance between being totally transparent versus allowing a scientific process to take place.”
The debate between the former and current editors has taken a turn toward the personal of late. In a response to criticisms from Frances and Spitzer, members of the DSM-V task force accused them of protesting the current process for financial reasons: “Both Dr. Frances and Dr. Spitzer ... continue to receive royalties on DSM-IV associated products” (www.psychiatrictimes.com/display/article/10168/1425806?verify=0).
Some critics of the DSM process express other concerns in addition to matters of transparency. It’s been pointed out that about 70% of current task force members have ties to the pharmaceutical industry, up about 14% for DSM-IV. A study of an earlier edition of the manual found that ties to the drug industry are particularly strong in working groups focusing on diagnostic areas in which drugs are the first line of treatment (Pscyhother Psychosom 2006;75:154–60). For DSM-IV, all of the members of the working groups for mood disorders and “schizophrenia and other psychotic disorders” had ties to drug companies.
“We recommended that they limit the number of people on these working groups with industry ties, making them a minority so they won’t dominate,” says Sheldon Krimsky, a coauthor of the study and an adjunct professor in the Department of Public Health and Family Medicine at the Tufts School of Medicine in Medford, Massachusetts. “But that hasn’t happened yet.”
The study noted that the pharmaceutical industry funds conventions and research related to disorders proposed for entry in the DSM because “what is considered diagnosable directly impacts the sale of their drugs.”
Members of DSM working groups are also wooed by drug companies, Krimsky says, because their involvement with the prestigious manual makes them valuable on the lecture circuit.
“If they start out not having industry connections, they will be tempted by industry to create them,” he adds.
But the DSM-V task force claims to be addressing these problems with conflicts of interest disclosure. Psychiatrists working on the manual are limited to US$10 000 in consulting fees from drug companies. Defenders of the process also claim that relationships with industry aren’t inherently harmful, and that collaboration by government, academia and industry aids development of pharmacological treatments (www.psychiatrictimes.com/display/article/10168/1364672?pageNumber=2).
Another criticism of the current task force is that they are being too ambitious, suggesting that DSM-V will be a “paradigm shift” in psychiatric diagnosis. Frances says a conservative approach to revising the manual is more appropriate. A radical change could only be justified if there were a fundamental leap in the understanding of what causes mental disorders, he says, and though advances in neuro-science and brain imaging show promise, that leap has yet to occur. Too many changes to the DSM will only lead to many people being mistakenly labelled as mentally ill and put on medications without good reason. In his email, Frances says the “ambition to be innovative, when no substantial innovation is possible, will likely lead to arbitrary changes that will often do more harm than good.”
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Previously published at www.cmaj.ca