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Who Benefits? DSM Conflicts of Interest

Conflicts, whether over ties to the pharmaceutical industry or fights over new categories of illness, come with the turf in revising psychiatry's most important reference.

"There is no such condition as schizophrenia, but the label is a social fact and the social fact a political event."
— R.D. Lang

As psychopharmacology — using drugs to treat mental disorders — has expanded to dominate psychiatry, so too has the Diagnostic and Statistical Manual of Mental Disorders' potential to boost the pharmaceutical industry's profits, and in so doing is creating new health problems for some using these meds.

Critics say the symbiotic relationship with pharmaceutical companies will only be exacerbated with the upcoming revision of the manual, known as the DSM-V. Consider the proposed Psychosis Risk Syndrome that Allen Frances describes as "the most worrisome of all suggestions," in his Feb. 11 commentary in Psychiatric Times. The new category has a lofty goal: weeding out individuals in the early states of schizophrenia, depression or other psychotic illnesses.

"It would be a great idea if we had a specific test that was a good predictor of who will become psychotic. If we had a fairly safe treatment, then it would be the most wonderful idea in the world," he says.

But Frances warns that if the new diagnosis makes it into the DSM-V, the influence of drug company marketers on primary care physicians could prescribe antipsychotic drugs like Zyprexa, Abilify and Seroquel needlessly to hundreds of thousands of teenagers and young adults. This would lead not only to the stigma of an inaccurate diagnosis, but a "health hazard in a vulnerable population."

Frances says there's evidence that antipsychotics are recommended much more frequently for people with Medicaid than private insurance.

The meds' side effects, obesity is a notable one, are also a worry. A study published last fall in the Journal of the American Medical Association found an average weight increase of 1 to 1.5 pounds a week for patients taking these kinds of medications, yielding metabolic changes that could result in serious diseases like diabetes and hypertension.

A series from on the controversy surrounding the latest Diagnostic and Statistical Manual of Mental Disorders:
Part I:Infallibility and Psychiatry's Bible (May 25)
Part II: Who Benefits? DSM Conflict of Interests (June 3)
Part III:Are You Normal or Finally Diagnosed (June 8 )

"It seems that in seeking the needle in the haystack, they'd be helping some people, but overall, the harm is so great, I see this as a public health nightmare," Frances says.

Lisa Cosgrove, a clinical psychologist and associate professor at the University of Massachusetts, traces such problems to the three most contentious words facing the DSM task force — conflict of interest, or COI.

Cosgrove began investigating conflicts in 2000 when a grad student alerted her to a DSM work group's testimony that helped get the drug Serafem approved for premenstrual dysphoric disorder. "A few members of the group were being paid by Eli Lilly," she says, which led her to co-author a 2006 study, "Financial Ties between DSM Panel Members and the Pharmaceutical Industry."

Cosgrove's study didn't establish a definitive causal relationship. She did find that the DSM working groups with the greatest financial ties to the pharmaceutical industry were those involved with mood and psychotic disorders, where pharmacological treatment predominates with an extremely profitable antidepressant/antipsychotic drug market.

"We leave it to others to see whether that constitutes a financial COI," she says. As for the latest DSM, Cosgrove sees the problem worsening.

In a written debate in the Psychiatric Times with the chair and vice chair of the DSM-V Task force, David Kupfer and Darrel Regier, Cosgrove and a colleague, Harold Bursztajn, critiqued the APA's "failed" COI policy, pointing out that 70 percent of the task force members reported direct industry ties. That's a 14 percent increase over the previous manual.

"Pharmaceutical companies have a vested interest in the structure and content of DSM, and in how the symptomatology is revised. Even small changes in symptom criteria can have a significant impact on what new (or off-label) medications may be prescribed," they wrote.

Kupfer and Regier dismissed their colleagues' arguments as "guilt by association." In their retort, the two wrote Cosgrove and Bursztajn are assuming "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."

Frances, for all his disputes with the task force leaders, agrees saying he's "absolutely sure there isn't a conflict of interest to help industry. ... I don't believe there's any conscious effort to benefit drug companies or increase research funding."

Legal Implications
Industry influence isn't the only concern plaguing the DSM. An expansion of the sexual disorder pedophilia to include pubescent teenagers known as "hebephilia" is raising the hackles of Allen and others who contend the added diagnosis will create a new group of criminals and constitute a misuse of psychiatry by the legal system.

"Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat," Allen writes.

Karen Franklin is a forensic psychologist in the Bay Area specializing in the evaluation and treatment of criminal defendants. She says the push to include hebephilia stems from a burgeoning cottage industry whose goal is to civilly commit sex offender as sexually violent predators.

"In some cases, these guys don't have a mental disorder, so mental disorders need to be invented or else it's unconstitutional to civilly commit them." For Franklin, the attraction to 11- to 14 year-old girls is not pathological but a "variant of normal" and may even be "evolutionarily adaptive."

This is where things get even thornier. Franklin says that just one clinic, The Centre for Addiction and Mental Health in Toronto, is wielding undue influence over the creation of hebephilia as a diagnostic category. "The chair of the sexual disorder task force, Kenneth Zucker, is chief psychologist at the center that did the research, and also the editor of the journal that published it. Two of the study’s co-authors serve with him on the journal’s editorial board, and one also serves on the DSM sexual disorders task force. So it's like a pipeline. The clinic does the only research that supposedly establishes this new disorder."

Franklin is responding to a paper that disputes her claims about hebephilia. Ray Blanchard, one of the center's clinicians who authored the report and chair of a DSM-V Sexual and Gender Identity Disorders sub-group, says the inclusion of hebephilia in the new DSM was intended to "increase the precision of diagnosis, not the number of people being diagnosed."

Zucker says that Franklin is just trying to "dig up dirt" where there is none.

"In small, specialty areas, you need to find experts able to review manuscripts, and, sure, people may know each other, but it's still subject to peer review," he says.

In fact, Zucker, who edits the journal in question, The Archives of Sexual Behavior, did publish seven criticisms of Blanchard's paper — including one by Franklin.

"[Franklin] belongs to the school of thought that if you throw enough spaghetti against the wall, some of it is bound to stick," he says.

It's no surprise that New Scientist writer Peter Aldhous' characterized such sparring as "psychiatry's civil war." These battles may seem arcane to the average person, but the proposed DSM-V also introduces several new disorders giving renewed credence to Herb Kutchins' and Stuart Kirk's 1997 book, Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. The DSM, rather than an objective, scientific instrument to help clinicians diagnose mental illness, is for them a tool aimed at pathologizing ordinary human behavior.