Information in this column has been sourced and paraphrased from Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus, by Paula J. Caplan, Vol. 7, Issue 1, APORIA and from A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice.
The website is ncbi.nlm.nih.gov/pmc/articles/PMC3282636/
One of the effects of the Diagnostic and Statistical Manual of Mental Disorders (DSM), used in psychiatry to diagnose mental illness, was the increase in prescribing psychotropic drugs.
Medications were used for very severe as well as milder DSM categories that had previously been treated with counselling and behavioural approaches.
While medicines have been effective in treating conditions like anxiety, depression and certain forms of psychosis, the pharmacological approach has only been partially effective in conditions like type I bipolar disorder, schizophrenia and personality disorders.
The potential for misusing the pharmaceutical approach has been decried by several critics.
And the phenomenon of “disease mongering” has been noted in the marketing of various drugs (e.g., the selective serotonin re-uptake inhibitors, SSRIs) for such conditions as “mild social anxiety,” which is been described as a “medicalization of shyness”.
The evolution of the DSM illustrates that what is considered to be “medical” and “scientific” is often not an immutable standard.
It is variable across time, culture and changes in dominant schools of thought.
The act of diagnosis in and of itself validates the very disease it names and defines when, in fact, these classifications themselves have been changed over the years from DSM-I to DSM-V.
What about valid scientific research?
What about results of randomized controlled trials?
What about the “evidence-based guidelines” that have been generated since DSM-III came into being?
Disturbing information of conflict of interest and industry influence has brought to light reasons to critically question what is presented to us.
In her commentary, Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus, Paula Caplan, of Harvard University’s DuBois Research Institute of Hutchins Center, presents the following account.
Caplan writes that “Allen Frances, arguably the world’s most powerful psychiatrist, spearheaded a massive, million-dollar project using psychiatric diagnosis to propel sales” of the drug risperidal, made by pharmaceutical giant Johnson & Johnson (J & J).
“Frances began the initiative in 1995,” says her article, “but his involvement has been little known, despite a court document written in 2010 that alleged what its author, an ethics specialist, called serious deception and corruption in that project.”
Frances is a longtime editor of the globally influential DSM.
“According to the court document,” Caplan’s article states, “Frances led the J & J enterprise that involved distortion of scientific evidence, conflicts of interest and other illegal and unethical practices. The author of the court document is Dr. David J. Rothman, a Columbia University specialist in the ethics of relationships between medicine and industry. The document is an expert witness report commissioned in connection with a Medicaid fraud case filed by the Texas attorney general at the time, Greg Abbott.”
As Caplan observes, the scrupulously documented Rothman Report, “contrasts starkly with the image of Frances as wedded to rigorous research and as an opponent of Pharma.”
“Rothman reported that, in 1995, the very year after DSM-IV appeared, Johnson & Johnson had paid more than half a million dollars (USD) to Frances and two of his psychiatrist colleagues to create an official-seeming document as the basis for promotion of one of their drugs. The following year, the drug company paid them almost another half million dollars to continue and expand the marketing campaign.”
The initial document produced was “Schizophrenia Practice Guidelines.”
Practice guidelines are presented to practitioners as advice on how to treat people who have received a particular diagnosis.
As Caplan notes, they “are considered the gold standard of evidence-based care because they aim to convey what is deemed to be the most reliable scientific evidence at a given time.”
The American Psychiatric Association (APA) itself produces most of the psychiatric practice guidelines, presented, Caplan observes, “as being based on objective evaluations of the relative effectiveness of various treatments for a specific condition.” But there is no arm’s-length regulation of these guidelines and Caplan notes that, “Nowhere in the DSM and its associated books and other products (such as casebooks, research reviews, and webinars) has the APA disclosed the poor scientific foundation of the symptom clusters underlying the proposed disorders.”
“It is troubling,” she adds, “that diagnostic categories with poor scientific basis have led to the production of ‘authoritative’ practice guidelines.”
There is no external regulation and those who create and promote guidelines are rarely held accountable if they misrepresent the relevant scientific research.
Investigation, she says, has shown that professional panels creating guidelines have tended “to increase the number of individuals considered to have the disease[s], none reported rigorous assessment of potential harms and most had a majority of members disclosing financial ties to pharmaceutical companies.”
A 2011 Institute of Medicine report stated, “There are no universally accepted standards for developing systematic reviews and clinical practice guidelines, leading to variability in the handling of conflicts of interest, appraisals of evidence, and the rigor of the evaluations.”
Solid information about what medication actually helps with what symptoms remains minimal — to the point, Caplan observes,
“that many prescribers will favour a trial-and-error approach in which they try to identify the best course of drug treatment for patients.”