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What Exactly Went Into My Psychiatric Diagnosis?

The diagnostic manual in psychiatry is rife with potential conflicts of interest

Even though your therapist might have the best of intentions, if she diagnoses you with a psychiatric problem, be aware of how that diagnosis was created!

Psychiatric diagnoses are not delivered to humanity from on high. Nor do they exist in the ether, waiting for humans to discover them.

Instead, the official guidelines for diagnosing these problems are arrived at via committees. The humans on these committees have often built their careers on the diagnosis in question, so they're anything but dispassionate about it.

Plus, many of the folks on these committees are receiving money from Big Pharma. Why should this matter? Since many psychiatric diagnoses come with recommendations to treat them with psychopharmacology, the entire process of constructing these diagnoses is anything but pristine and objective. That's why everyone ought to be a bit suspicious about the factors that lead to the creation of any psychiatric diagnosis.

To try to help matters, the diagnostic manual in psychiatry, the DSM-IV-R, is currently being rewritten. In response to critics of past manuals, individuals who are working on this manual have pledged to limit their income from the pharmaceutical industry to $10,000 or less per year until the completion of their work on the manual. 

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However, this agreement doesn’t change the fact that current authors of the DSM might have received substantial payouts before joining the DSM committees, or might stand to profit big-time from pharma after the manual is published. Indeed, researchers recently found that “three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry.” Furthermore, they note that “the most conflicted panels are those for which pharmacological treatment is the first-line intervention.” (Or, more simply put, situations in which drugs are the first treatment).

Another concern is that even if the authors personally adhere to the self-imposed limits, how much pharmaceutical funding is being funneled into their respective academic departments by way of lectureships, endowed chairs, or sponsored research? Nothing prohibits the departments of committee members from receiving substantial sums of money annually from pharma.  

The researchers in the recent study also note that “panel members are not required to disclose unrestricted research grants from industry.” Unrestricted grants are those in which a department can decide how and where to spend the money, as opposed to those grants that place tight requirements on how and why they are dispersed. Does anyone believe that an unrestricted grant can't influence the person who receives it?

If we ask judges to recuse themselves from legal cases in which they have a conflict of interest, is it too much to ask DSM committee members not merely to disclose their financial ties to the pharmaceutical industry but to beg off from them completely?

All of this is significant because psychiatric diagnoses carry power of various sorts. They affect the pharmaceutical industry: The more diagnoses there are, the more problems exist to throw medications at. Diagnoses also affect the insurance industry, since certain diagnoses have implications for how often someone might be seen, and the extent that insurers can refuse to pay for needed care.

Further, given the stigma of mental illness, labels carry power over how society sees people with a diagnosis—and how they see themselves—especially because they are couched in scientific terminology and possess an air of objectivity. I hope to explore the dynamics of these types of power in future posts.

 

All references are from Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190.

Wes Boyd is on faculty at Harvard Medical School and is an Attending Psychiatrist at Cambridge Health Alliance and Children’s Hospital Boston.

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