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Follow the Money

The APA offers a fait accompli that DSM-5 will be published in 2013 despite the poor Field Trial results, the petition requesting independent review from fifty-one mental health professional associations, the opposition fromand.
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According to its own original schedule, DSM-5 was to have conducted its quality control in a Stage 2 of field testing. Stage 2 would be for rewriting criteria sets that did poorly in Stage 1 and retesting them to ensure they could now achieve reliability.

Stage 1 was a disaster -- poorly designed and badly implemented. Constantly missing deadlines, it came in 18-30 months late (depending on how you count its start date). And many diagnoses had crazily low reliability, far below acceptable historical standards, suggesting either that the criteria sets were poorly written or the testing poorly done, or more likely both. The results were pretty much uninterpretable- except for confirming all the other indications that DSM-5 was badly off track and needed lots more work.

APA was faced with 2 choices: 1) go ahead with Stage 2 to clean up the mess; or 2) declare Stage 2 unnecessary and publish a poorly edited, unreliable, and untested DSM-5. APA chose the second option and is rushing toward a forced, premature birth of DSM-5.

Since there is no pressing need to publish the DSM-5 quickly, let's follow the money. The APA budget depends heavily on the huge publishing profits generated by its DSM monopoly. APA needs the money badly. It is losing paying members; other sources of funding are also on a downward trend; and its budget projections require a big May 2013 injection of DSM-5 cash.

And APA also has to adjust to the bloated cost of doing DSM 5 -- an incredible $25 million dollars. For comparison, DSM-IV cost about $5 million, more than half of which came from outside funding. APA feels compelled to recoup on this huge, mostly wasted, investment by getting DSM-5 to the bookstores ASAP. The assumption is that the market is captive and that DSM-5 will be a best seller despite its quality problems.

APA treats DSM-5 like a valuable publishing property, not as a public trust that importantly impacts on people's lives and public policy. It is excellent at protecting its "intellectual property" with confidentiality agreements and at protecting its trademark and copyright with bullying threats of lawsuits. But APA has been sadly incompetent and wildly profligate in the day-to-day work of actually producing a safe and scientifically sound DSM-5. The rush now is all about money.

APA Medical Director Jay Scully strongly disagrees with me. He states his case in a piece titled "DSM-5 Inaccuracies: Setting the Record Straight."

Dr. Scully offers the fait accompli that DSM-5 will be published in 2013 despite the poor Field Trial results, the petition requesting independent review from fifty-one mental health professional associations, the opposition from The Lancet and New England Journal of Medicine, the terrible beating DSM-5 is taking in the press, and from outraged consumer groups. Nothing in his response offers any reason for DSM-5 adhering to his arbitrary timeline. There is nothing to indicate that he understands that DSM-5 is the public trust and not an APA cash cow. Dr. Scully is asking us to believe ten very unbelievable things:

1) That its three legal entities aren't just different parts of one APA pocket;

2) That the American Psychiatric Foundation just cares about charity -- somewhat hard to believe since APF was recently picked as America's 7th worst charity by a watchdog group. This is a pretty spectacular accomplishment given the number of charities in our country.

3) That the APA isn't concerned about the budget deficit caused by reduced publishing profits and poor attendance at its annual meeting;

4) That the APA isn't worried about its rapid loss of membership and isn't trying to find more publishing dollars to fill the budget gap;

5) That the APA reserves haven't fallen below the one year's operating budget generally expected for a non-profit;

6) That DSM-5 has cost $25 million (five times more than DSM-IV, which I worked on) because it has had such a wonderfully open process;

7) That the DSM-5 can produce a usable product by next May;

8) That the APA isn't completely dependent on the publishing profits from its DSM monopoly to avoid suffering deficits that would be between $5-10 million a year.

9) That DSM-5's Stage 2 Quality Control was not skipped purely for financial reasons. What would be another excuse -- certainly not scientific rigor?

10) That DSM-5 is not being rushed to press next May to fill what would otherwise be a gaping hole in the APA budget.

You decide how much, if any, of Dr. Scully's arguments make sense. My view -- if you want to understand why an unreliable and unsafe DSM-5 is being rushed prematurely to market -- is to "follow the money."

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

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