Thursday, January 23, 2014

It's Official: DSM 5 is a Pissing Contest


First, I want to tell you that I have a conflict of interest when it comes to discussing both Dr. Kupfer and Dr. Frances: they were both my teachers, and they are people I hold in esteem.  Dr. Kupfer ran a summer program in psychiatry for college students, the Mellon Fellowship in Psychiatry for Undergraduates, and in the summer of 1983, as a college student aspiring to go to medical and become a psychiatrist, I was one of 8 students from across the country to receive one of these grants. It was an opportunity that opened doors for me and changed my life, and I remember Dr. Kupfer as a warm, kind teacher and I remain grateful the wonderful opportunity he gave me.  Dr. Allen was one of my professors at Cornell University Medical College in the late 1980's.  He was one of the distinguished gentlemen in a white coat at the front of the lecture hall, and while I don't recall any personal interactions with him, he was part of the corps of people who taught and influenced me and held my interest for psychiatry in a environment where one of my attendings told me I was wasting my life and would do more good as a plastic surgeon than I could ever hope to do as a psychiatrist.  They can fuss about DSM 5; as their former student, they still hold my respect.  I will not be purchasing the DSM 5.

Before I copy and paste Dr. Frances's discussion of the latest DSM-5 conflict of interest, I want to tell you something that was omitted from his post that I'm pasting below.  Dr. Frances was the Chair of the DSM-IV Task Force.  He's taken up forces against the DSM-5, and in 2009, Dr. Kupfer  was one co-author in article that publicly accused Dr. Frances of having a conflict of interest with DSM 5.

Schatzberg, Scully, Kupfer, and Regier wrote in 2009 in Psychiatric Times, Setting the Record Straight: A Response to Frances Commentary on DSM-V:

Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing. - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf

Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing. - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing. - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Dr. Frances opened his commentary with the statement, "We should begin with full disclosure."  It is unfortunate that Dr. Frances did not take this statement to heart when he did not disclose his continued financial interest in several publications based on DSM-IV.
inally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.
  - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing. - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf

Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.”  It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV.  Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V.  Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing. - See more at: http://www.psychiatrictimes.com/dsm-5-0/setting-record-straight-response-frances-commentary-dsm-v#sthash.SYWl3gp2.dpuf
  I imagine Dr. Frances is enjoying the chance to respond here, copied and pasted from his Psychology Today blog:  

A serious DSM 5 conflict of interest is revealed

There is a new and strange twist that further complicates the sad DSM 5 saga.
For some time, Bernard Carroll has served as an unofficial conscience of psychiatry, tirelessly exposing scientific sloppiness and ethical laxity. He recently made a new find, documenting that the Chair of the DSM 5 Task Force had failed to disclose a long-standing and significant financial conflict of interest.
Here's what happened. While using his DSM 5 pulpit to strongly promote the value of dimensional diagnosis, the DSM 5 Chair (and several associates also working on DSM 5) were secretly forming a company that would profit from the development of commercially available dimensional instruments. And unaccountably, he failed to disclose this most obvious of conflicts of interest while simultaneously lauding the DSM 5 conflict of interest policy.
   Having been goaded by Carroll's findings, the American Psychiatric Association proceeded to conduct what turned out to be a remarkably superficial internal investigation. APA agreed that a conflict of interest had definitely occurred and that it had not been disclosed--but minimised its importance, failed to address or explain many of the most pertinent facts, and recomended no action. This critique of the report makes obvious that APA is doing its best to slip past the problem rather than learn from it. 1boringoldman.com
A much more objective and informative commentary on the details and significance of this DSM 5 conflict of interest is available at neuroskeptic.
The solution to the immediate problem couldn't be clearer--a full disclosure and explanation of what happened; an unconditional apology for all the mistakes that were made; an assurance that no one will profit financially because the new dimensional instruments will now be offered free for public use rather than being sold commercially; and the development of stronger APA policies, policing, and punishments to prevent similar future recurrences.
Instead of doing the obvious right thing, APA has responded with its typical superficial public relations patois of damage control inanities. The blatant attempt at cover up exacerbates and institutionalises the initial mistakes--making them seem even worse than they are and further tarnishing the already tattered ethical reputation of APA.
Mickey Nardo MD represents all the psychiatrists in the trenches who have had more than enough of incompetent APA leadership. He writes what is by far the best available psychiatric blog under the misleadingly modest nom-de-blog 1boringoldman. Nardo is definitely not boring and by my standards is not that old. Anyone who regularly reads his blog will agree that he lives up only to the last part of the title--he is indeed a mensch.
After writing an enlightening series of blogs dealing with various aspects of this conflict of interest mess and APA's inadequate respite to it, Nardo developed a damning timeline connecting the dots, and finally wrote the following impassioned open letter to the APA Trustees and Assembly. His goal is to stimulate the APA at long last to do the right thing--to correct its persisting pattern of lax ethical oversight over both itself and the profession.
Psychiatry is a noble and essential calling that should not be judged by the faltering incompetence of the American Psychiatric Association. Nardo's letter speaks for itself and cries out for a fearless self inventory and forthright response from the APA. We need to rectify the mistakes of the past if we are to establish the much needed higher standards for the future.

"An Open Letter To APA From Mickey Nardo MD
It has been a dark time for psychiatry. Since the investigations of Senator Grassley exposed significant corruption and unseated three chairs of Psychiatry in 2008, there has been a series of disturbing exposures involving widespread ghost writing, guest authoring, and questionable clinical trial reporting; escalating widely publicized settlements by pharmaceutical companies involving psychoactive drugs and implicating prominent psychiatrists; charges of overmedication and entrepreneurialism; the drying up of the pharmaceutical pipeline; recurrent charges of ubiquitous Conflicts of Interest in high places; and an ongoing and divisive process that spanned the DSM-5 Revision process. Besides the gravity and frequency of the problems, their handling by the administrative levels in our specialty have played poorly in the eyes of the public and our currency is at an all time low.
The recent revelations of multiple unreported Conflicts of Interest by the Chair and other members of the DSM-5 Task Force threaten to throw gasoline on an already uncontrolled fire. The public memorandum from the Speaker of the Assembly, Mindy Young, reads more like a defense attorney’s closing argument than an impartial investigation, and is being viewed as a "whitewash" – threatening to add to our reputation of sweeping things under the rug rather than thoroughly exploring and dealing with charges of impropriety. It focuses on the concrete impact of their actions, but doesn’t address the more cogent issue of conduct unbecoming persons of high responsibility – people we entrust to make important decisions. Our specialty is in a steady decline, much of it our own making, and we don’t need to help it along by ignoring this obvious issue of integrity.
I have prepared below a Timeline of the major events in these revelations, with links to the salient documents involving Kupfer and his business associates. I have also provided a link to commentary by a respected weblog professional, Neuroskeptic. I ask you to read these materials carefully and appoint an outside panel that can review them independently. The Trustees approaching this issue with integrity, open-mindedness, and thoroughness will go a long way towards restoring our reputation as the ethical medical specialty that we need to be, and set a new precedent that Conflicts of Interest will be thoroughly pursued."
Nardo's Timeline of events



4 comments:

Joel Hassman, MD said...

Tough choice there Dinah. Kupfer doesn't deserve any respect per what has been revealed by outside parties, I have interacted with Dr Frances when he was the editor of Journal of Psychiatric Practice, and he seems to be more realistic with what psychiatry should be offering.

Pissing contest? Wow, that is a very descriptive title. I don't know why I am responding here, but, I guess I hold out hope you are realizing being polite and politically correct won't win you brownie points. But, why are you still a member of the APA?

Frankly, I think you are the most realistic of the three of this blog. Just my opinion.

Hypocritical Joel.

1BOMfan said...

1boringoldman needs to be given some kind of special honorary status in psychiatry. He is brilliant. Glad that Dr. Frances takes note.

Are people really only polite just because they want brownie points? Can it not be that there are people who still believe in etiquette?

Dinah said...

I continue to belong to the APA because I get something tangible out of belonging, and I believe the over-arching mission of the organization is good. The world has shades of gray, people are fallible, sometimes good people say or do dumb things, and sometimes I disagree with the views of others (and by the way, I'm always right). But if I wrote off every person and organization every time they supported/promoted/believed in something that went against my grain, I'd be living a lonely life. Name calling doesn't help, I'm going for mutual respect, when feasible, and accepting that no one, myself included, is perfect or necessarily consistent in the application of their values and the avoidance of hypocrisy. Anyone else is free to say the pro-con balance of belonging to APA is such that they'd rather not belong, but the other thought would be to join and try to encourage change.

Anonymous said...

One of my favorite bloggers on the Mad In America Site, Dr. Sandra Steingard, just posted about this issue. After not being sure whether she should say anything for various reasons, she said this:

"But in the end, I decided that I had an obligation to use whatever platform I have to bring more attention to this issue. For me, one of the biggest problems we have in psychiatry is unacknowledged COI. Given the sensitive nature of the work we do, the power we can wield over people’s lives, the history of our improper relationships with Pharma – even if it turns out all rules were followed – that is not good enough. We should be above reproach."

Well said, Dr. Steingard.

http://www.madinamerica.com/2014/01/conflict-interest-dsm-5-apa/

AA