Response to "Conflicts of Interest"

Dr. Ness et al. raise important concerns. The authors are correct that disclosure alone is an important but not sufficient check against the possibility of bias by experts involved in the development of APA practice guidelines and DSM.

For this reason, additional checks have been built into the development process for both publications. These checks include advance review of disclosures before experts are appointed to work groups, exclusion of experts who have a significant conflicting industry relationship or who derive significant income from a single industry relationship, inclusion of experts who have no significant industry relationships, and broad iterative review and revision of drafts.

Every APA practice guideline, for example, is circulated for review to about 50 experts; a number of allied organizations, including allied professional societies and patient advocacy organizations; all APA components, including the Assembly and Board of Trustees; and any APA member on request. Between 600 and 800 comments are generally received. Using a consensus process, substantive revisions by the work group chair, the guidelines Steering Committee chair, and the practice guidelines medical editor address these comments. This iterative process minimizes the possibility that bias from a work group member will survive in the final draft. A similarly extensive review and approval process is envisioned for DSM-V.

APA's ultimate goal is to create a DSM and practice guidelines that are evidence based, scientifically valid, and clinically useful. Excluding all persons with industry relationships from participating fully on the work groups that develop these publications would result in a different kind of bias: silencing the collective expertise, knowledge, and judgment of many of our most distinguished researchers on psychiatric diagnosis and treatment. The current approach attempts to strike a sensible balance. These publications have had a positive impact on patient care, and their scientific basis lends credibility to the field of psychiatry. It is important that they continue to be developed, using a process that is rigorous, open to many viewpoints, and transparent. Input from APA members on how the current approach may be refined is welcomed.