Here's a Secret: The DSM Process Isn't

The good news is this: according to the latest poll commissioned by APA, we are succeeding in improving public understanding and acceptance of psychiatry. APA was ahead of the curve on the issue of relationships with the pharmaceutical industry; we won commendations from the accrediting body for the rigor of our vetting process for educational programs; our journals do not mix advertisements with editorial content; our records are clear and clean. We sent five and a half years of those records to Sen. Grassley's office—and the New York Times—on September 2, 2008. The standard of disclosure and divestiture we set for members on the various work groups developing DSM was higher than that of any other organization of which I am aware and certainly more than the previous editions of DSM. We require that each participant's aggregate income from the pharmaceutical industry (as well as some other activities) not exceed $10,000 a year.

Yet the major media continue to run allegations that the DSM process is being conducted “in secret” and fraught with possible conflicts of interest. I want to be sure you have the facts. The current DSM process is far more inclusive, rigorous, and transparent than any editions that have preceded it and very likely more than the process by which other medical specialties decide upon diagnostic categories. The names of the participants have been made public; anyone can “Google” them. They can also be accessed at APA's Web site at<www.dsm5.org>. The regular reports of the DSM leadership to the APA Board are posted on the same Web site, where there is an invitation for public comment (click on “Make a Suggestion”), and drafts will be widely circulated for comment as they are posted. Anyone—members and nonmembers alike—may make comments and access the DSM database after registering at the DSM Web site.

Some media reports have focused on the confidentiality agreement that DSM participants have signed. The form can be accessed on the DSM Web site as well. No invited participant refused to serve on the basis of the agreement, and no participant has complained that the agreement curtails the freedom to discuss the issues as well as the process so as to further his or her work. In fact, participants working on DSM have already given many scientific lectures at grand rounds and meetings all over the world to foster understanding, debate, and discussion of DSM. DSM is a precious product of APA. We are acutely aware of the implications of DSM for science, for clinical care, and for the image of our field. We will have invested 13 years of intensive literature review, analysis, and field trials before DSM-V is published. We take our responsibility to protect the quality and dissemination of DSM very seriously. As a result, the current leadership has taken steps to protect APA's investment in DSM-V.

The so-called “secrecy” requirement for DSM-V specifically allows discussion for the purpose of enhancing the scientific process; the confidentiality agreement is solely for the purpose of protecting the DSM development process from exploitation for private gain. We have new DSM leadership because we are interested in an independent evaluation of the current diagnostic paradigms and do not want the process unduly encumbered by past assumptions.

Another accusation that surfaces in the media is that the categories in DSM are politically determined and decided by vote. Sometimes the media reference the 1973 decision to remove homosexuality as a mental disorder from DSM. It is entirely appropriate that diagnoses evolve as new research appears. The leadership of APA recognized, 36 years ago, that psychiatrists had been seeing only those homosexual individuals who presented for psychiatric care, and that the stigma against homosexuality was psychiatrically toxic to homosexual people. New research not limited to patient populations failed to demonstrate any causal association between psychopathology and sexual orientation. Of course the decision was finalized by a vote of the APA elected leadership. In the absence of a dictator, or engraved stone tablets descending from the heavens, that is the only way to formalize a decision.

The DSM process, like all human endeavors, is not perfect. But it is ironic that the most rigorous, open, and inclusive process in medicine should be branded as “secretive” and “political.” When you read or hear negative stories about DSM, contact the APA Office of Communications and Public Affairs at [email protected]. More importantly, counter accusations of secrecy and bias with the facts.▪