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Research Special Paper

Undisclosed financial conflicts of interest in DSM-5-TR: cross sectional analysis

BMJ 2024; 384 doi: (Published 10 January 2024) Cite this as: BMJ 2024;384:e076902

Linked Opinion

Financial conflicts of interest in the DSM—a persistent problem

Rapid Response:

Clarification of DSM-5-TR COI review process and corrections of erroneous analysis in Davis et al”

Dear Editor

We are writing to correct the erroneous statements and misimpressions in the article by Davis, et al. (1) about the possible conflicts of interest (COI) in the production of the American Psychiatric Association’s (APA) DSM-5-TR. (2) In contrast to assertions in the article, the APA took the risk or appearance of COI very seriously. All participants in the process had to disclose all sources of income, which were reviewed by the APA’s COI Committee. All proposed revisions to the text were reviewed for possible COI by the DSM-5-TR COI Review Editor, and proposed changes that could be perceived as possibly benefiting industry ( e.g., adding a new proprietary laboratory test to the Diagnostic Markers section of the text) were flagged and subjected to an additional level of review, which involved considering whether the contributor’s outside interests may have had an impact on their recommended text changes. If there was even the possibility of an impact, the proposed change was not implemented. Additional restrictions to potential conflicts of interest were given to the decision makers for proposed DSM-5-TR content, who included the DSM-5-TR Chairs (Co-Chairs and Vice-Chairs) and the DSM Steering Committee members (all listed in the front matter of DSM-5-TR). Before participation was permitted in these roles, these individuals were required to disclose receipt of more than $5,000/year in income from industry and to divest any amount above that threshold; most had no such industry income.

Moreover, the DSM-5-TR revision was focused almost entirely on updating the material in the text about the disorders (e.g., prevalence, comorbid conditions) to reflect the results of studies that had appeared since DSM-5 was published in 2013 (as described in the DSM-5-TR Introduction section, “DSM-5 Text Revision Process”). All proposed changes needed to be supported by newly published data before they could be approved. In addition, as DSM is a diagnostic and not a treatment manual, the revision eschewed any mention of management and treatment recommendations, focusing exclusively on diagnostic issues, thus excluding the kinds of information most likely to be of potential benefit to industry.

Finally, it is quite evident from their analysis that Davis et al. made a number of erroneous assumptions about the DSM-5-TR revision process and its scope. The authors essentially tried to replicate the methods used in their past analyses of industry ties among DSMIV (3) and DSM-5 (4) Workgroup and Task Force members, except that instead of relying on published or Internet data on financial affiliations, the analysis in the current article relied on data from the Open Payments database maintained by the Centers for Medicare and Medicaid Services. However, the DSM-5-TR revision process, detailed in DSM-5-TR and referenced in further detail separately (5), differed quite significantly from the prior DSM-IV and DSM-5 revision processes. Applying the authors’ methods to the DSM-5-TR development process yields results that simply do not make any sense. For example, the authors claim to have “examined the extent and type of conflicts of interest of panel and task force members,” but there was no task force for DSM-5-TR, and it is unclear to whom they are referring. It should be noted that an article explaining the DSM-5-TR revision process and its rationale in detail appeared almost a year before this paper was accepted for publication (5). Had the authors read the earlier article, they would have discovered that their analysis yielded results that are misleading and uninterpretable.

Conflicts of interest in medicine are far too important to be addressed with inaccurate data. The DSM-5-TR process was notable for its rigorous and thorough efforts to ensure the integrity of all revisions to the DSM.

1. Davis LC, Diianni AT, Drumheller SR. Undisclosed financial conflicts of interest in DSM-5-TR: cross sectional analysis. BMJ 2024;384:e076902. doi: 10.1136/bmj-2023-076902.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision (DSM-5-TR). 2022.

3. Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L. Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychother Psychosom 2006;75:154-60. doi:10.1159/000091772.

4. Cosgrove L, Krimsky S. A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists. PLoS Med 2012;9:e1001190. doi:10.1371/journal.pmed.1001190.

5. First MB, Gogtay N, Clarke D, Eng A, Yousif L, Appelbaum PS. DSM-5-TR: rationale, process and overview of changes. Psychiatr Serv 2023;74:869-875. doi: 10.1176/

Competing interests: Dr. Appelbaum is the Chair of the DSM Steering Committee for the American Psychiatric Association (uncompensated). Dr. First was the Co-chair for the DSM-5-TR revision. Personal financial interests: Book royalties from American Psychiatric Publishing for DSM-5-related books (DSM%-TR Handbook of Differential Diagnosis, Learning DSM-5-TR BY Case Example; Honorarium for serving as a faculty member for Neurotorium, an on-line educational platform supported by the Lundbeck Foundation. Organizational financial interests: Book and licensing royalties from American Psychiatric Publishing for the Structured Clinical Interview for DSM-5; paid to Columbia University Department of Psychiatry. Nonfinancial interests: Consultant to the World Health Organization for the International Classification of Diseases, Mental, Behavioral, and Neurodevelopmental Disorders chapter; Member – DSM Steering Committee - American Psychiatric Association; Member: SNOMED Mental and Behavioural Health Clinical Reference Group.

11 January 2024
Paul S. Appelbaum
Chair, DSM Steering Committee; Dollard Professor of Psychiatry, Medicine & Law
Michael B. First, MD (Co-Chair, DSM-5-TR; Professor of Clinical Psychiatry Columbia University)
Columbia University
New York, NY, USA