DSM5 in Distress

The DSM's impact on mental health practice and research

Follow The Money

APA puts publishing profits above public trust

According to its own original schedule, DSM-5 was to have conducted its quality control in a Stage 2 of field testing. Stage 2 would be for rewriting criteria sets that did poorly in Stage 1 and retesting them to ensure they could now achieve reliability.

Stage 1 was a disaster — poorly designed and badly implemented. Constantly missing deadlines, it came in 18-30 months late (depending on how you count its start date). And many diagnoses had crazily low reliability, far below acceptable historical standards-suggesting either that the criteria sets were poorly written or the testing poorly done, or more likely both. The results were pretty much uninterpretable — except for confirming all the other indications that DSM-5 was badly off track and needed lots more work.  

APA was faced with 2 choices: 1) go ahead with Stage 2 to clean up the mess; or 2) cancel Stage 2 and publish a poorly edited, unreliable, and untested DSM-5. APA cancelled Stage 2 and is rushing toward a forced, premature birth of DSM-5.    

Since there is no pressing need to publish the DSM-5 quickly, let's follow the money. The APA budget depends heavily on the huge publishing profits generated by its DSM monopoly. APA needs the money badly. It is rapidly losing paying members; other sources of funding are also on a downward trend; and its budget projections require a big May 2013 injection of DSM-5 cash.

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And APA also has to adjust to the bloated cost of doing DSM-5 — an incredible $25 million dollars. For comparison, DSM IV cost about $5 million, more than half of which came from outside funding. APA feels compelled to recoup on this huge, mostly wasted, investment by getting DSM-5 to the bookstores ASAP. The assumption is that the market is captive and that DSM-5 will be a best seller despite its quality problems.

APA treats DSM-5 like a valuable publishing property, not as a public trust  that importantly impacts on people's lives and public policy. It is excellent at protecting its 'intellectual property' with confidentiality agreements and at protecting its trademark and copyright with bullying threats of lawsuits. But APA has been sadly incompetent and wildly profligate in the day to day work of actually producing a safe and scientifically sound DSM-5. The rush now is all about money.  

APA Medical Director Jay Scully strongly disagrees with me. He states his case in a piece titled 'DSM-5 Inaccuracies: Setting the Record Straight'  Here are Dr Scully's comments (provided in full):

"In his Huffington Post blog dated May 30, 2012 titled 'DSM-5 Costs $25 Million, Putting APA in a Financial Hole,' Allen Frances, M.D., demonstrates either an embarrassing lack of knowledge and understanding of financial reporting or an intentional misrepresentation of facts in his continuing effort to attack the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is published by the American Psychiatric Association. Contrary to Dr. Frances's contention, APA is not in a "financial hole" at all. In fact, the very treasurer's report he purports to cite from in page two expressly states that there was a "preliminary year end surplus of $2.4M for the APA (the (c) (6) nonprofit entity) on a stand-alone basis and a deficit of $2.7M for the APF." The APF, or American Psychiatric Foundation, is an independent charitable subsidiary of APA whose mission is to advance the understanding, prevention, and treatment of mental disorders through public education, research, and training.

APF has no relationship with DSM-5. The APF deficit was a planned deficit encountered to support its philanthropic work, which benefits psychiatry, patients, and the public. The APA (the (c) (6) entity with the $2.4 million surplus) is responsible for the development of DSM-5. APA reports to its board of trustees on a consolidated basis, offsetting APF's deficit with APA's gains."

"Dr. Frances's statement that the consolidated deficit "was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5" is either ignorant or intentionally false. And Dr. Frances apparently missed slide six of the report about reserves, which demonstrate an extremely healthy cash reserve that increases year after year. The strength of APA's reserves and the fiscally conservative approach of consolidating balances of the APA and the APF for a balanced consolidated budget demonstrate the competence of APA leadership."

"Dr. Frances also complains that the revision of DSM-5 has been more expensive than that of DSM-IV. That should not come as a surprise to anyone, particularly Dr. Frances. DSM-5, unlike DSM-IV, invited comments from the world, and the work groups and task force considered every one of the more than 25,000 comments received and conducted further research where indicated. DSM-5 has employed an open process where all comments are considered, revisions are made where appropriate and the ideas are sent out again for comment with the process repeating itself. The transparency associated with the process is expensive, but it is beneficial, and will help to ensure that DSM-5 is a meaningful tool for diagnosis of mental illness when it is published, on time, in 2013."

By saying  "when it is published, on time, in 2013," Dr. Scully offers a fait accompli. He has set the DSM-5 publication date without any attention to the lousy Field Trial results, the petition from fifty-one mental health professional associations, the opposition from the Lancet and New England Journal of Medicine, the terrible beating DSM-5 is taking in the press, and the outraged consumer groups. Nothing in his response offers any reason for DSM-5 adhering to his arbitrary timeline. There is nothing to indicate that he understands that  DSM-5 is the public trust and not an APA cash cow. Dr Scully is asking us to believe ten very unbelievable things:

1) Its three legal entities aren't just different parts of one APA pocket;

2) the American Psychiatric Foundation just cares about charity- somewhat hard to believe since APF was recently picked as America's 7th worst charity by a watchdog group. This is a pretty spectacular accomplishment given the number of charities in our country. See  http://allreaders.net/top10worstcharities.html

3) APA isn't concerned about the budget deficit caused by reduced publishing profits and poor attendance at its annual meeting;

4) APA isn't worried about its rapid loss of membership and isn't trying to find more publishing dollars to fill the budget gap;

5) APA reserves haven't fallen below the one year's operating budget generally expected for a non-profit;

6) DSM-5 has cost $25 million (five times more than DSM IV) because it has had such a wonderfully open process;

7) DSM-5 can produce a usable product by next May;

8) APA isn't completely dependent on the publishing profits from its DSM monopoly to avoid suffering deficits that would be between $5-10 million a year.    

9) DSM-5's Stage 2 Quality Control was not cancelled purely for financial reasons. What would be another excuse?

10) DSM-5 is not being rushed to press next May to fill what would otherwise be a gaping hole in the APA budget.   

You decide how much, if any, of Dr Scully's arguments make sense. My view — if you want to understand why an unreliable and unsafe DSM-5 is being rushed prematurely to market — "Follow The Money."

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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