DSM-5: Dimensionality: Conflicts of Interest

In DSM-5 – Dimensional Diagnoses – More Conflicts of Interest? which I posted on December 23, 2013, I drew attention to the fact that David Kupfer, MD, in his position as head of the DSM-5 Task Force, was vigorously promoting a dimensional model of assessment while at the same time was positioning himself to benefit financially if such a system were to be adopted by psychiatry generally.

Dr. Kupfer’s potential conflict of interest was exposed by Bernard Carroll, MD PhD, and has been investigated and publicized by Mickey Nardo, MD.

The APA investigated Dr. Kupfer’s activities, and in their report they acknowledged that he should have disclosed his interests, but they assured us all that no harm had been done.

Psychiatry has had its share of scandals in the past few years, and the response from the profession’s leadership has been remarkably consistent:  inconsequential censoring of the culprits, followed by a speedy return to business as usual.  The general attitude seems to be that the public memory is short; that the storm will blow over; and that all will be well.  And above all – there must be no admission of fundamental systemic problems within psychiatry itself.

And there was a time when those kinds of tactics worked.  But not any more.  Because now we have the Internet – and we have Mickey Nardo – who blogs as 1 boring old man.

Dr. Nardo is not letting this thing go.  On January 21, he posted open letter to the APA.  The opening paragraph is compelling:

“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.”

Dr. Nardo challenges the thoroughness of the APA’s investigation, which, he notes, is being widely perceived as a “whitewash.”  He continues:

“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.”

The foundation of psychiatry is the notion that virtually all problems of thinking, feeling, and/or behaving are in fact illnesses that need to be treated by medically trained practitioners primarily through the use of psycho-pharmaceutical drugs.  The DSM is the document that lists and codifies these putative illnesses, and as such must be regarded as the main cornerstone of this foundation.

Even the possibility that the revision of this document has been corrupted by financial considerations should be sending Richter 9 shock waves through the entire profession.  But instead, there’s barely a murmur.

In the article mentioned above, Dr. Nardo has created a time line of the major events in this affair.  It makes interesting reading.

There is an urgent need for Dr. Kupfer to meet the press, and to provide complete and candid answers to the various questions that are being asked.  Riding out the storm, and waiting till it blows over, is no longer a viable strategy for public figures in any walk of life.

 

  • cannotsay

    Phil,

    Am I the only one who feels that this outrage by Bernard, the old man guy, and now Sandra Steingard feels like a bad taste practical joke,

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

    This is the comment I have waiting for moderation there,


    First, I have to say that I have come to respect you more from your
    first postings in MIA in which you looked like the female version of Dr
    Moffic. I still have qualms with some of your positions, like coercive
    psychiatry, but still, I think that you have grown into somebody I can
    respect.

    With this said, I find this fabricated outrage quite comical.

    And since I like humor a lot, I would illustrate the issue with a
    joke about San Francisco that was very popular among conservatives like
    yours truly years ago. I do not find the internet reference, so it must
    have lost some popularity. I have to retell it using my own words, which
    might not be as funny.

    The joke was something like this. It talked about a party attended by
    the mayor and the San Francisco elite. The party was full of the usual
    negatives about San Francisco that have become anathema in the
    conservative consciousness: wild alcohol consumption, heavy illegal drug
    usage (cocaine, crack, heroin, etc), sessions of group sex, old gay men
    having sex with minors, etc. Suddenly the mayor decides to pull a stunt
    in the middle of the room with a dominatrix and a bottle of Vodka with
    everybody watching. The mayor is unlucky and the bottle falls to the
    floor where it is left for the remaining of the party.

    The next day, the San Francisco Chronicle, upon learning about the
    party, decides to take the story to its front page in a responsible
    exercise of investigative journalism. The headline “San Franciscans
    express outrage that their mayor doesn’t recycle bottles of Vodka in his
    parties”.

    It must be an “insider thing”, but seriously worrying about this when
    people are dying everyday of the effects of the drugs that
    psychiatrists prescribe to treat psychiatry’s invented diseases seems
    like a practical joke that only psychiatrists can understand :D”

  • Phil_Hickey

    cannotsay,

    Thanks for coming in.

    In my view, contests are won (and lost), not only in the great battles, but also in the myriad skirmishes that occur on the periphery. The DSM is one of the foundation stones from which psychiatry derives its perceived legitimacy, and as such is, in my view, a valid target for criticism.

    You’re correct in saying that we need to condemn psychiatry for its blatant destructiveness, but I think we should also critique the structures and procedures that sustain this destructiveness.

    You must do what you must do, of course, and I’m not trying to dictate to you how to wage your particular campaign. We’re a movement, but we’re also individuals, each with our own perspectives and experiences. Psychiatry has hurt, and as you accurately point out, killed a great many people. Anger is an appropriate response to this kind of activity, especially when the activity is shrouded in self-serving deception and propaganda.

    But, psychiatry is deeply entrenched, worldwide, in our laws, our cultures, and in our economics. It’s not going to go away overnight, no matter how much you and I might like to see that. It’s a long haul, and personally, I welcome the input of anyone who is willing to critique any facet of psychiatry.

    I do this for two reasons. Firstly, because I believe that each critique, including yours and mine, becomes part of a cumulative effect. And secondly because, in my experience, when people find one flaw in the psychiatric fabric, they usually go on to find more. Condemnation, however, often generates a sense of beleaguerment, and drives people away. I think we should, and must, challenge those psychiatrists who continue to proclaim the “infallibility” and unmitigated “virtue” of psychiatry, particularly those who promote the expansion of the psychiatric net; and I think we should expose and condemn the destructive practices that the profession routinely embraces.

    But I don’t think we should condemn those who are taking significant steps in our direction. It’s a big tent, and we need all the help we can get.

    Again, I’m not trying to tell you what to do. I’m just sharing my perspective.

    Best wishes.

  • cannotsay

    You are wiser than me, so you are probably right on your approach. At the same time, the abolition of slavery required a civil war and the passage of the 1964 Civil Rights Act required a massive and public shaming of the supporters of the Jim Crow laws.

    So while I see your contributions invaluable (I have used your posting on the invalid scientific foundations of psychiatry elsewhere) I have come to the conclusion that dramatic change in curbing psychiatric abuse will not come of just talking. I am a very peaceful and non violent person so I am thinking more along the lines of creating some fund that can be used to sue psychiatrists everywhere. Something like what CCHR does, but without connections to Scientology or any religion.

  • Francesca Allan

    Given the power of our opponents, I think a hopeful strategy would be to provide alternatives. If patients clearly do better with Soteria Houses, psychiatrists will eventually lose their power as the public comes to see incontrovertible evidence that our methods are better. Much of my resentment against the psychiatric reform movement is that everybody’s raging against the machine but not many are advocating effective and humane alternatives.

    I am not very confident in legal strategies. Here, we have the Supreme Court of Canada’s Starson v. Swayze decision which was a landmark decision that separated the notion of competence from the decision whether or not to comply with treatment. The Court defined competence as the demonstrated ability to appreciate the potential consequences of your decision. That judgement was been pretty much ignored in later cases, mostly due to the fact that Professor Starson was hardly the poster boy for noncompliance. Now, if it had been Allan v. Coastal Health Authority on the other hand 🙂

  • cannotsay

    Here is a fact that I hope we can all agree on: in all areas of life, not only psychiatry, power is NOT something that those who have it give out easily.

    In business, established companies try every trick of the book to prevent competition from new players with things like regulation, technology that is difficult to impossible to replicate, etc. These tactics cannot prevent people from buying products that people find attractive but that these companies do not produce, which is why companies eventually come and go, but not without a struggle. In other words, the free market defends the consumer from abuses.

    In politics, governments do the same with their political opponents, only, at least in democratic countries, people can vote and get rid of them when they abuse too much.

    In geopolitics, I don’t see anytime soon the UK or France giving up their veto power at the UN security council even though it makes absolutely no sense that they have it after each lost their respective empires due to decolonization during the 1960s and 1970s (and as far as I remember, even Canada didn’t stop being an official colony of the UK until the early 1980s).

    So, psychiatry has managed to have their invented diseases embedded in our laws (the DSM is explicitly mentioned in both state and federal law). They have managed to make forced drugging legal. They have managed to make drugging “the standard of care”. They have managed, at least in the US, to make it legal to advertise these drugs to consumers.

    To think that these people are going to quietly surrender their power out of “being nice” or because suddenly they realize that they practice a quackery is to understand very little about human nature. They know all too well that they practice a quackery:

    https://www.youtube.com/watch?v=j5t_bl7-hHg

    So I see legal action, public shaming and CCHR type of tactics as the only real chance at changing things.

  • Phil_Hickey

    cannotsay,

    I don’t know about “wiser” – but I do hear what you’re saying. You’re probably aware of Jim Gottstein and PsychRights.

  • cannotsay

    Yes I am and I am a huge fan of the work he does.

    I have hesitated to contact him (his email address is public knowledge) because that would imply a huge step forward and losing a lot of my anonymity. I will “come out” in my own terms :D. That said, I think that Jim Gottstein/PsychRights on steroids is the solution. He recently had to settle a case for which he got the go ahead from an appeals court because the district court made clear to him in no uncertain terms that in his court he was headed for defeat and that he would be responsible for lawyer fees of the opposite party.

    Imagine if Jim had a budget of 10 million dollars a year to sue people, buy, that would make a difference!

  • Francesca Allan

    Cannotsay, this is in response to your “To think that these people are going to quietly surrender their power
    out of “being nice” or because suddenly they realize that they practice a
    quackery is to understand very little about human nature.”

    You have completely misrepresented my position. It’s got nothing to do with waiting for them to be “nice.” It’s got to do with us providing alternatives and getting a proven track record that’s duly noted by both the authorities and the public. That is action worth taking. Ranting and raving about how we were harmed is not going to get us anywhere.

    It really doesn’t matter if they ever become aware that they practice quackery. If better alternatives are available (and – critical point – potential patients are aware of them), their opinion will be irrelevant.

  • cannotsay

    In all likelihood you will be disappointed. The evidence that there are alternatives to the psychiatric fraud has been there since at the very minimum Loren Mosher proposed the Soteria model. The answer of organized psychiatry was to use its muscle to ostracize him.

    The APA is an evil organization. Evil needs to be confronted, not “talked to out of evil”. They know all too well what the situation is and they are very happy to keep it at “talking about this or that” including a phony scandal as to who is to keep the profits, Bernard Carroll or Kupfer.

  • Francesca Allan

    There may be “evidence of” alternatives but that’s not good enough. We need actual treatment centres available – right here, right now, in my hometown, in all hometowns.

    Yet again, I remind you that I am not talking about “talking them out of evil” or “waiting for them to be nice.” I am talking about GIVING DISTRESSED PEOPLE OTHER OPTIONS! We can make psychiatry obsolete.