Copyright: © 2012 Cosgrove, Krimsky. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Introduction

All medical subspecialties have been subject to increased scrutiny about the ways by which their financial associations with industry, such as pharmaceutical companies, may influence, or give the appearance of influencing, recommendations in review articles [1] and clinical practice guidelines [2]. Psychiatry has been at the epicenter of these concerns, in part because of high-profile cases involving ghostwriting [3],[4] and failure to report industry-related income [5], and studies highlighting conflicts of interest in promoting psychotropic drugs [6],[7]. The revised Diagnostic and Statistical Manual of Mental Disorders (DSM), scheduled for publication in May 2013 by the American Psychiatric Association (APA), has created a firestorm of controversy because of questions about undue industry influence. Some have questioned whether the inclusion of new disorders (e.g., Attenuated Psychotic Risk Syndrome) and widening of the boundaries of current disorders (e.g., Adjustment Disorder Related to Bereavement) reflects corporate interests [8],[9]. These concerns have been raised because the nomenclature, criteria, and standardization of psychiatric disorders codified in the DSM have a large public impact in a diverse set of areas ranging from insurance claims to jurisprudence. Moreover, through its relationship to the International Classification of Diseases [10], the system used for classification by many countries around the world, the DSM has a global reach.

After receiving criticism that DSM-IV had no financial disclosure of panel members, to its credit the APA instituted a mandatory disclosure policy [11]. The DSM-5 panel members are required to file financial disclosure statements, which are expected to be listed in the publication, and the APA has made a commitment to improve its management of financial conflicts of interest (FCOIs).

This new APA requirement makes the DSM's disclosure policy more congruent with most leading medical journals and federal policies on FCOI. FCOIs are widely recognized as problematic because of the data showing a clear connection between funding source and study outcome whereby results are favorably biased toward the interests of the funder [12]–[14]—what has been referred to as the “funding effect” [15]. Some have argued that greater transparency of financial interests may facilitate a decline in FCOIs and a decrease in the potential bias that accompanies them, and that it may encourage professionals and consumers to more critically evaluate medical information [16]. Others are not sure that disclosure will reduce FCOIs and the potential for bias, because transparency alone just “shifts the problem from one of ‘secrecy of bias’ to ‘openness of bias’” [15]. Additionally, there is the concern that disclosure may open the door for subterfuge [17]. That is, when researchers or panel members list every affiliation that they have ever had, including funding from federal agencies, it can create a “signal-to-noise problem,” thereby obscuring the truth about deeply problematic financial relationships with industry.

We have reported elsewhere on industry relationships with DSM-5 task force members [18]. Although the composition of the task force has changed slightly since its formation in 2007 (e.g., Pilecki et al. [19] found 72% of the members had ties in early 2011) industry relationships persist despite increased transparency. Currently, 69% of the DSM-5 task force members report having ties to the pharmaceutical industry. This represents a relative increase of 21% over the proportion of DSM-IV task force members with such ties (57% of DSM-IV task force members had ties). This finding is congruent with emerging data from fields outside of psychiatry suggesting that transparency of funding source alone is an insufficient solution for eliminating bias [20]–[23].

In 2006 we analyzed all DSM-IV panel members' financial associations with industry [24]. We have undertaken a similar analysis for DSM-5 panels, which allowed us to compare the proportions of DSM-IV and -5 panel members who have industry ties. There are 141 panel members on the 13 DSM-5 panels and 29 task force members. The members of these 13 panels are responsible for revisions to diagnostic categories and for inclusion of new disorders within a diagnostic category.

Three-fourths of the work groups (Figure 1; [2],[4]–[6],[8],[10]–[12]) continue to have a majority of their members with financial ties to the pharmaceutical industry. It is also noteworthy that, as with the DSM-IV, the most conflicted panels are those for which pharmacological treatment is the first-line intervention. For example, 67% (N = 12) of the panel for Mood Disorders, 83% (N = 12) of the panel for Psychotic Disorders, and 100% (N = 7) of the Sleep/Wake Disorders (which now includes “Restless Leg Syndrome”) have ties to the pharmaceutical companies that manufacture the medications used to treat these disorders or to companies that service the pharmaceutical industry.