Remember DSM-5? After all the criticisms, the street protests and the scholarly debates, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was finally published by the American Psychiatric Association (APA) in May 2013. And then... well, that was it. The launch itself was a something of an anticlimax - as I predicted in 2010, "When DSM-5 does arrive... it will be a non-event. By then the debates will have happened." But now a strange story is emerging that could reignite the controversy. First some background: one of the main claimed innovations in the DSM-5 is that it promotes the use of 'dimensional' or quantitative measures of symptoms. Traditionally the DSM has been about all-or-nothing, categorical diagnoses ("He is depressed", "She has schizophrenia"). The 5th edition, for the first time, also recommends the use of severity scales. It's a move away from digital and in the direction of analogue - such is progress in psychiatry.
In fact, what we might call the 'dimensional turn' is more of a statement of intent than anything else. The core of DSM-5 remains the categorical diagnoses - 245 of them, by my count. The dimensional stuff is effectively an appendix. Nonetheless, it's something. But why is the DSM promoting symptom scales? Or more to the point, why is it suddenly promoting them now, given that dimensional measures have been used in psychiatry for 60 years? This is where it gets interesting. The head of the APA's DSM-5 task force, David Kupfer, stands accused of failing to disclose a conflict of interest which - arguably - means that he has a financial stake in the concept of dimensional assessment. It all started with a paper in the journal Archives of General Psychiatry (now JAMA Psychiatry) called Development of a computerized adaptive test for depression. The first author was statistician Robert. D. Gibbons of the University of Chicago (a veteran of psychiatric statistics). The last (senior) author was David Kupfer. The Gibbons et al paper presents a software program to help rate the severity of depression, an 'adaptive' questionnaire. Whereas a normal questionnaire is just a fixed list of items, the new system chooses which questions to ask next based on your responses to previous ones (drawing questions from a bank of items adapted from existing depression scales). The authors say this provides precise measurement of depression across the full continuum of severity. We'll leave aside the question of whether it works (see Part 2 of this post for that) but going by what it claims to do, it's clear that CAT meshes quite nicely with the DSM-5's inclination towards dimensional measures. Perhaps you've guessed what Kupfer's conflict of interest is. He (and Gibbons and colleagues) seem to be preparing to sell their computerized adaptive test (CAT). They have incorporated a company, Psychiatric Assessment Inc. (PAI). This raises the disturbing notion that Kupfer, in his capacity as computerized dimensional product seller, could benefit financially from his prior championing of dimensional assessment in his capacity as DSM-5 head. Ironically, Kupfer was one of those who outraged many by accusing Allen Frances - architect of DSM-IV and critic of DSM-5 - of having a financial conflict of interest in opposing the revision, on the grounds that Frances was getting royalties from DSM-IV-related book sales (by which logic, every author in history has had a financial conflict of interest in their own ideas). In late 2012 the Gibbons et al paper appeared in Archives of General Psychiatry. In response, Bernard Carroll wrote to the editor pointing out that the authors had not declared the extent of their conflicts of interest (CoI). Incidentally, Carroll is also cited in the article, as the creator of one of the contributing questionnaires, the CRSD. Carroll was right, and Gibbons et al eventually apologized "to the editors and readers" for their failure of full disclosure, in a letter (which did not, however, acknowledge that it was Carroll who spotted the problem.) Nor did it note that the first author, Gibbons, is on the editorial board of JAMA Psychiatry (I have been unable to tell whether or not he was on the board of Archives of General Psychiatry at the time of publication.) But it gets worse - Kupfer also made a Conflict of Interest statement to the APA in late 2012 - neglecting to mention that several months earlier, Gibbons had formed PAI (in November 2011) and given Kupfer (and also his wife, Ellen Frank) shares in the company. Kupfer was actually put up before the APA's version of a Congressional Committee, the Assembly of the APA, for this. And now, in a letter dated last week (14 January 2014), the APA decided that he was wrong to fail to disclose a CoI:
We believe that Drs. Kupfer, Frank and Gibbons should have disclosed their interest in PAI on APA’s conflict of interest form in 2012, and they did not do so. Dr. Kupfer did include his stock ownership in PAI on his April 2013 disclosure. Even though PAI has no product or revenue, and never has had a product or revenue, it is a company related to psychiatry and the stock interest should have been disclosed.
But the APA went on to say that the DSM-5's dimensional turn was not influenced by commercial interests:
Use of dimensional measures dates back to the 1960s... from 2003 there were entire conferences dedicated to exploring the use of dimensional measures in DSM-5. The dimensional measures used in field testing were selected by the end of 2010 – over a year before PAI was formed. Drs. Kupfer, Gibbons, and Frank did not advocate for inclusion of CAT in DSM-5.
Such is the APA's retrospective. They then turn their hand to fortune-telling, and predict that
PAI will not gain financially from DSM-5’s inclusion of dimensional measures in Section 3 or if CAT is included in future versions of DSM. If and when PAI develops a commercial product with CAT, it will not have any greater advantage because of DSM-5’s inclusion of dimensional measures in Section 3 than the dozens of dimensional measures currently being marketed by others.
Maybe. Although the APA don't consider that PAI, unlike its rivals, will be able to use its association with the head of the DSM-5 committee as a selling point. We'll have to wait and see whether they do that, because at present, the CAT is not available and does not seem to be being actively marketed. There is a website for Adaptive Testing Technologies but it's little more than a FAQ and a list of big names - for now. Still, the APA seem satisfied that commercial interests were not allowed to corrupt the decision-making process behind DSM-5. Even if they're right, this wouldn't exclude the possibility that Kupfer and others are in the process of trying to 'cash in' on the DSM-5 - and started doing so before the ink was even dry. But the indispensable 1boringoldman blog (the source for much of the information in the post - I'd also like to thank Uri Cohen for his input) has just put up a very useful Timeline of these events, which makes the APA's rosy picture look naive - at best. It's worth checking out in full; although I see no 'smoking gun', it's clear that the development of the CAT and of the DSM-5 were intertwined, from as early as 2002. But what about the CAT itself? Is it a breakthrough? And who funded it, anyway? Stay tuned for Part 2.
Gibbons RD, Weiss DJ, Pilkonis PA, Frank E, Moore T, Kim JB, & Kupfer DJ (2012). Development of a computerized adaptive test for depression. Archives of general psychiatry, 69 (11), 1104-12 PMID: 23117634