Millions of Dollars of Pharma Money Went to the DSM-5-TR Authors

In a new study, researchers found that about 60% of the authors working on the latest edition of psychiatry’s diagnostic bible (the DSM-5-TR) had financial ties to the pharmaceutical industry. In total, more than $14.2 million of pharma money went to the DSM-5-TR task force and review group members.

“The amount of money received from pharmaceutical companies by individuals with decision making authority over the revision process raises questions about the editorial independence of this diagnostic manual,” the researchers write.

The study was conducted by Lauren Davis and Brian Piper at the Geisinger Commonwealth School of Medicine and Lisa Cosgrove at the University of Massachusetts-Boston, as well as other researchers from both institutions. (Full disclosure: Cosgrove was my advisor in graduate school.)

Cosgrove has previously demonstrated that the majority of authors of the previous versions of the DSM also had financial ties to pharma, including 100% of the authors creating the diagnoses for depression, bipolar disorder, and schizophrenia in the DSM-IV.

The researchers note that although it is not possible in this case to prove that financial conflicts of interest influenced the DSM development process, there is copious evidence showing that receiving money from industry creates biased research literature and biased guideline development, with researchers across all specialties in medicine far more likely to come to pro-industry conclusions if they received industry money.

“The impact of financial conflicts of interest on the medical literature, including randomized clinical trials, meta-analyses, and clinical diagnostic and practice guidelines, has been well documented for more than two decades. Indeed, researchers have consistently shown that conflicts of interest lead to subtle but impactful pro-industry thinking and conclusions,” the researchers write.

Psychiatry’s Bible

This latest version of the DSM, a text revision to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), published by the American Psychiatric Association (APA), came out in 2022.

The DSM has been criticized by prominent figures in psychiatry such as Kenneth Kendler, who wrote that the diagnoses do not “correspond to reality” and Allen Frances, who warned of how more and more normal human experiences were being labeled “mental illnesses.”

One of the most controversial new diagnoses in this edition is the reframing of grief into a “mental illness” called “prolonged grief disorder (PGD).” The criteria? Continuing to miss your child, spouse, or sibling every day after their death. Grieving for more than six months, according to the criteria, is considered “abnormal” or “excessive.” (The DSM indicates that it must have been a year since the loved one’s death, but the main diagnostic measure, the PG-13, indicates that only six months must have passed. The other main diagnostic book, the ICD, also lists six months.)

According to a 2023 study, more than a third of those who have lost a loved one met the criteria for PGD (an even higher percentage was found in those whose loved one’s death was traumatic). Yet 98.1% of the people in that study said that this level of grief is normal, not indicative of “mental illness.”

As with all of the diagnoses in the DSM, there was no scientific basis required for the creation of a whole new illness out of a natural part of life—just the consensus of experts in the field, who voted to include it in the new edition.

Researchers are already searching for drugs to sell to bereaved people, including antidepressants as well as naltrexone, a drug used for alcohol and opioid addiction, as a potential “treatment” for what they describe as an addiction: “a disorder of attachment and a craving and yearning for the deceased from whom they are separated.”

Industry Influence in the DSM-5-TR

The APA has expressed a desire to be transparent regarding how the DSM diagnoses are decided and the financial conflicts of interest held by the task force and workgroup members. Nonetheless, the APA has not released the minutes of the review group discussions, nor are the financial disclosures of the authors printed in the DSM or online.

However, the Open Payments website includes all pharma and device industry money paid to US doctors, and this can be matched against the listed authors of the DSM. There were 168 authors; researchers were able to find data for 92 of them (the remaining authors were not doctors or were not from the US). Of those, 86 were on the various panels (review groups focused on specific diagnostic categories), while six were task force members (overseeing the larger project).

Fifty-five of the 92 authors had received payments from industry (59.8%). Two of the six task force members received money from industry, as did 53 of the review group panelists.

There were five review groups in which at least three-quarters of the panelists received money from industry:

• Neurodevelopmental disorders (80%)
• Obsessive-compulsive disorders (80%)
• Disruptive, impulse control, and conduct disorders (100%)
• Neurocognitive disorders (75%)
• Medication-induced movement disorders (75%)

Of those who received payments, more than 90% received money for meals, about 70% received compensation for travel, and about 70% received money for consulting services. The largest dollar value spent by industry went to research grants.

Nineteen of the authors (34.6% of those who had industry ties) received money for serving as an industry speaker or “key opinion leader.”

The researchers write that serving as a key opinion leader is “widely recognized as an egregious financial conflict of interest because the role of the key opinion leader is essentially a marketing one; the talks given are usually presented at educational events sponsored by industry. As one author pointed out, key opinion leaders are hired by industry because, as the terms suggests, they can lead (or change) opinions.”

The creation of new diagnoses can be a way for pharma to expand its reach, according to the researchers, but so can minor changes to the diagnostic criteria for existing disorders. For instance, diagnoses can be applied to more people by changing the age range or by decreasing the number of criteria required.

In order to combat this bias, according to the researchers, experts chosen to author the DSM should be free of financial ties to industry. In particular, those who serve as industry’s key opinion leaders should be prohibited. The DSM process should also be more transparent, for instance by releasing the meeting minutes so that the public can see how the changes were decided.

As Cosgrove writes in an accompanying editorial, “A key step to creating trustworthy clinical guidelines is ensuring that they are developed by experts who are free of industry ties, as organisations such as the Institute of Medicine recommended over a decade ago. In the case of the DSM, this recommendation is also important because panel members are able to eliminate disorders—not just add new ones—and thus could play a vital role in tackling overdiagnosis and overtreatment.”

 

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Davis, L. C., Diianni, A. T., Drumheller, S. R., Elansary, N. N., D’Ambrozio, G. N., Herrawi, F., . . . & Cosgrove, L. (2024). Undisclosed financial conflicts of interest in DSM-5-TR: cross sectional analysis. BMJ, 384, e076902. doi: (Full Text)

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