Monday, March 8, 2010

Financial conflicts and other problems with the proposed DSM-V

I have hesitated to weigh in on the debate raging over the proposed changes to the DSM-V (psychiatry's diagnostic bible), in large part because others more literate in psychiatric minutiae have already done so. To wit: Dr. Allen Frances in the Psychiatric Times, Dr. Edward Shorter in the The Wall Street Journal, and Dr. Daniel Carlat on his blog.

All three of these experts agree that the DSM-V (which, like previous DSMs, was created by psychiatrists appointed by the American Psychiatric Association) is dangerously broadening the categories of various disorders, which will have the net effect of creating profitable new markets for drug companies. As Frances, the chair of the previous DSM-IV task force, puts it:
DSM5 would create tens of millions of newly misidentified false positive “patients,” thus greatly exacerbating the problems caused already by an overly inclusive DSM4. There would be massive over-treatment with medications that are unnecessary, expensive, and often quite harmful. DSM5 appears to be promoting what we have most feared--the inclusion of many normal variants [like grief] under the rubric of mental illness, with the result that the core concept of "mental disorder" is greatly undermined.

However, the pundits seem to disagree when it comes to one particular change: subsuming Asperger's and other similar disorders under the broadened category of autistic spectrum disorders. While Shorter and Carlat think it's a good idea, Frances argues that this consolidation presents serious problems -- see again his Psychiatric Times essay. At a dinner party last night, I heard similar concerns from several mental health professionals, including allegations that the change may have been pushed for less than noble reasons -- i.e. financial gain.

But before I get to the possible conflict of interest here, let me enumerate their larger concerns:

1. There seems to be no scientific basis for subsuming Asperger's syndrome under the tent of autistic spectrum disorders.
2. Many children and adolescents with Asperger's benefit from a specially constructed type of environment (with special supports at school to bolster the social skills they lack). If these children are subsumed under the autism tent, there may be less emphasis on constructing such supportive environments and they may be more likely to be prescribed powerful anti-psychotic drugs like Abilify and Risperdal that are now approved for use with autism. Forget the fact that these drugs have significant side effects. If this happens, many Asperger's patients will not get the specialized attention they need.
3. There may be a temptation to diagnose children with mild autism as having Asperger's, thus undercutting the reality that while some people with Asperger's are highly functioning individuals, many others are severely disabled. As a result, people with severe Asperger's may also not receive the intensive care they need.

Now to the potential conflict of interest with the proposed change. As it turns out, one of the members of the DSM-V task force is Catherine Lord, a professor at the University of Michigan, who gets big royalties from a diagnostic test she helped develop (known as ADOS) that is used to diagnose autistic spectrum disorders in children. As it turns out, the subcategories for the ADOS test fit very neatly into the new criteria proposed for the autistic spectrum disorders in the DSM-V.

Now, according to an APA disclosure report I found online, Lord has agreed not to accept more than $10,000 from "industry sources" each year from the time the DSM-V is approved until its publication (the report says that will be in 2012, but recently the APA agreed to delayed publication of a new DSM until 2013).

What I want to know is: does this agreement include all the royalties Lord currently receives from the ADOS diagnostic test and the expensive bucket of toys that come with it? And if so, what happens after the DSM-V is published when all those royalties start flooding back in?

More importantly, should Lord have been allowed to sit on the DSM-TV task force in the first place and influence major policy changes in psychiatric diagnoses that will affect millions of vulnerable children? I think not.

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