©Sylvia Johnson Photography 2007
FIG1One of APA's most important
contributions to our profession has been the Diagnostic and Statistical
Manual (DSM). The DSM is the ultimate reference used by
psychiatrists and other mental health professionals not only in the United
States but throughout the world to diagnose and classify mental disorders.
Each edition represents the most up-to-date science and provides a base for
appropriate clinical care, as well as further research on mental illness.
The preparation of DSM-V is under the direction of a task force
(under which are topically related work groups), and the final product will be
reviewed and approved by the APA Assembly before receiving official approval
from APA's Board of Trustees. This column provides more background regarding
the DSM appointment process—a process in which we have been
pioneers in setting standards of disclosure and limits.
Members of the DSM-V Task Force were nominated based on
recommendations of clinical leaders, the research community, and psychiatric
subspecialty and other health and mental health groups. They are research
scientists from psychiatry and other disciplines, master clinicians, as well
as consumer and family advocates. In addition, their experience includes a
focus on basic medical science, genetics, epidemiology, statistics, and public
health and in subspecialties such as child and adolescent psychiatry,
addictions, geriatric psychiatry, ethics, and cross-cultural issues.
The APA Board of Trustees is committed to assuring that DSM is as
free as possible from any bias and potentially conflicting relationships with
entities that have an interest in psychiatric diagnoses and treatments.
Disclosure of real or perceived potential conflicts has become the standard of
journals and other medical publications. For DSM-V, however, it was
insufficient merely to disclose competing interests; rather, APA needed to
determine what the limits of such relationships should be.
Consequently, we looked at procedures of other medical specialties, medical
journals, medical organizations such as the Association of American Medical
Colleges (AAMC), and the federal government, including the National Institutes
of Health and the Food and Drug Administration. We understood that almost
two-thirds of medical research in this country is funded by industry—the
government and foundations provide the remainder—and that clinical
science is dependent on nongovernmental funding. We recognized t hat ever yone
has some competing personal or professional interests, not all of which are
financial; we also were aware that whatever criteria we endorsed for
disclosure, limits, and divestiture could be perceived as arbitrary. Some APA
members advocated for allowing no current or previous industry support, while
others stated that full disclosure would suffice. After considerable
discussion, we adopted a more stringent standard than that of federal agencies
or the recommendations of the AAMC.
Full disclosure of income from all industry sources is required for the
three calendar years prior to appointment; income limits were set beginning in
calendar year 2007 and continue for the duration of each member's work on
DSM. These limits require that each member's total income from
industry sources (excluding unrestricted research grants in which the
researcher has total control over the content and implementation of the
research program) would not exceed $10,000 in any calendar year, and that
stock or shareholdings (excluding blind trusts, mutual funds, and pension or
retirement funds) would not be worth more than $50,000 total. We also
prohibited appointees from participating in any capacity in industry-supported
symposia at an APA annual meeting during their tenure (excepting those who had
made a previous commitment for the 2007 meeting). While much attention was
focused on financial relationships with industry, we also set limits on
personal/professional relationships of participants to avoid other perceptions
of influence or bias.
We also see these principles as a first step in fostering transparency and
minimizing perceptions of conflicts, or real conflicts, and just as we
require ongoing reporting by all DSM participants, we also will
continuously review our principles to ensure the integrity of this important
contribution to science and care. A recent APA review of appointees'
disclosures demonstrated the complexity of funding psychiatric research and
education, but also documented the accuracy of appointees' full
We have been gratified at the willingness of leaders in the field to abide
by these principles and to participate in DSM-V at some personal
financial cost. Their commitment to the best science will ensure the
best-quality product as well as the best patient care. ▪