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Rapid response to:

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:

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

Dear Editor

Drs. Applebaum and First state that the APA adopted an extensive process to ensure that any industry ties would not influence their DSM-5-TR revisions. Why then did APA not disclose those with ties, and list the amount that each member had received from industry? If the APA had presented such information to the public, there would have been no reason for us to use the Open Payments database to present an overview of the industry money that flowed to the DSM-5 TR- authors.

We agree with Bernard Lo, MD, Director Emeritus of the Program in Medical Ethics, University of California, San Francisco, who said in response to our study, that the lack of public disclosure is critical.

"Part of the report should be, 'Here are the conflicts of interest reported by the members of the panel…’ Failure to do that in the DSM-5-TR is unacceptable from an ethical and transparency point of view…..This failure to adequately address conflicts of interest doesn't promote transparency and it doesn't promote public trust in the diagnostic criteria."[1]

Do Drs. Applebaum and First consider the $14+ million that flowed to the DSM-TR-5 authors from just 2016-2019 a trivial amount? (It should also be noted that this is likely a de minimis figure). The authors of the letter also state “If there was even the possibility of [a financial conflict of interest having] an impact, the proposed change was not implemented.”

What was the criteria by which the assessments were made? How many people were DSM panel members that were determined to have problematic FCOI and so asked to recuse themselves? For example, how could it be acceptable that the members of one panel received over 8.4 million USD from industry?

The authors state that the DSM-5-TR does not make treatment recommendations. However, as they well know, industry has benefitted greatly from the expansion of diagnostic boundaries (and number of diagnostic categories) since DSM-III was published. This diagnostic expansion is what has enabled the extraordinary increase in the use of psychiatric drugs over the past 40 years. Indeed, we agree with Allen Frances, MD, who chaired the DSM-IV task force and who is Chair Emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine who stated:

“...any individual from any professional association that has an intense interest in any given diagnosis will always be on the side of expanding that diagnosis and expanding the treatment for it.”[1]

Prior to developing this study, Dr. Cosgrove had contacted Dr. First asking for information on the panel and task force members. He did not provide this information because the APA was not ready to do so.

Dr. Cosgrove later emailed the following question:

"I also wondered if you knew why APA decided not to publicly disclose names and disclosure docs for the TR. Is APA still using the COI policy that they instituted for DSM 5?"

However, she did not receive a response from Dr. First.

If APA is committed to transparency, why did the APA not make disclosure forms available to the public? We used the names of those listed in leadership positions in the DSM-5-TR as the 6 task force members (now referred to as “chairs”).

Perhaps most important, why didn't APA simply follow the Institute of Medicine’s (now the Academy of Medicine) recommendations for developing trustworthy diagnostic and clinical practice guidelines? These recommendations include the fact that guideline development groups should be free of conflicts of interest and should be a multidisciplinary group that adequately represents patient stakeholders.

Finally, replication is the hallmark of science and we are happy to make our raw data available to any investigators who want to verify our findings.


Competing interests: Dr. Cosgrove has no competing interests. Dr. Piper reports contributing to an osteoarthritis research team supported by Pfizer and Eli Lilly (2019-21) and reports receiving grants from the Pennsylvania Academic Clinical Research Center.

15 January 2024
Lisa Cosgrove
Brian Piper (Geisinger Commonwealth School of Medicine, Department of Medical Education, Scranton, PA, USA)
University of Massachusetts-Boston
Boston Massachusetts USA