Frances Responds to APA: "Important Questions Need Answering"

I had intended not to reply to the silly suggestion made by the APA leadership that I wrote my critique of the DSM-V process out of financial motivations:

"Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing."

I had expected we would be conducting a useful discourse on the concrete issues and was surprised by the unenlightening personal exchange.  Unfortunately, the DSM-V leadership refuses to discuss any of the substantive questions I have raised and, I am told, instead persists in the shallow rationalization that whatever I say is financially motivated.

Let's set the record straight so that we can redirect attention to the important questions that need answering. My royalties from DSM-IV-related books have totaled about $10,000 per year. I was always surprised they lasted this long, expected that they would end soon, and never regarded this as a motivation for anything. I did not mention the royalties in my commentary disclosure simply because they never occurred to me as I was writing it.   As far as Dr Robert Spitzer is concerned, the idea that his concerns about openness and transparency, which go back to spring 2008 when he wrote a letter to the Board of Trustees questioning the wisdom of the confidentiality agreements, is motivated by financial concerns, is simply ludicrous.   Furthermore, none of the royalties from Bob Spitzer’s casebooks or structured interviews have ever been paid directly to him but instead have funded research activities in his department at Columbia.

So what are my motivations and why did I write the commentary and all of these subsequent communications? Until recently, I had very little interest in DSM-V and felt the new team deserved a clear field. Three things I learned at the recent APA meeting annual meeting forced me to give up my previous complacency.   Most worrying was the announcement that field trials were about to begin without any of the DSM-V options having been posted and vetted by the field - this is a recipe for damaging unintended consequences. Second, I learned that subthreshold and premorbid disorders were still being seriously considered. Third, I discovered that the DSM-V Task Force has had no reporting relationship to the Council on Research, which may explain its many missteps. I wrote the commentary out of a simple and disinterested concern that the work on DSM-V, unless corrected soon, would be harmful to patients, practitioners, and also to the APA. I don't like being part of a controversy and this is no fun, but I felt I had a responsibility to point out the serious problems in how DSM-V is being done and to offer to recommendations based on my experience.

It was my hope that the commentary would open a reasoned discussion. When the DSM-V leadership responded so defensively, I realized it would be necessary for the Trustees to intervene and this is why Dr Spitzer and I wrote to them.  I will happily drop out of this controversy once the DSM-V process is put on sound footing. 

Which brings us back to the questions that have been raised repeatedly and so far have been completely avoided. I repeat them once again and invite reply in the hope that it is never too late to have constructive discussions on how to improve the DSM-V process and product.  

Why not…

1. Post all the suggested wordings for the DSM-V criteria sets well before considering field trials?

2. Post all the literature reviews supporting the changes?

3. Post the proposed methods for conducting field trials?

4. Postpone beginning field trials until there has been adequate time for the field to thoroughly review and critique the above postings and for the Workgroups to integrate the suggestions into the criteria sets that will then be field tested?

5. Eliminate the confidentiality agreements?

6. Greatly increase the numbers and diversity of the pool of advisors?

7. As with all previous DSMs, establish the usual reporting chain from the DSM-V Task Force to the APA Council on Research?

8. Eliminate the artificial and unrealistic publication deadline of 2012 in order to ensure adequate time for a quality DSM-V?