The DSM was originally conceived simply as a manual for the objective classification of psychiatric symptoms, then gradually came to be regarded as the reference in psychiatry (1). Several aspects of its development have been criticised, however: arbitrary creation or removal of certain mental disorders; the increasing number of characteristics portrayed as mental disorders (180 in the 2nd version [DSM-II] published in 1968, versus 350 in the 4th version [DSM-IV] published in 1994); and the pharmaceutical industry's stranglehold over its development and dissemination, encouraging the overuse of pharmaceuticals in the field of mental health (2-6).

It had already been shown back in 2006 that members of the APA in charge of developing DSM-IV had conflicts of interest, particularly in diagnostic areas for which pharmacological treatments are proposed (2). A team of US academics investigated the conflicts of interest of contributors to the revised 5th version (DSM-5-TR, published in 2022) (6).

The authors used the US database Open Payments to search for any conflicts of interest among US-based doctors who were members of the APA's DSM panels or task force. About 60% of these 92 members had a financial link with at least one pharmaceutical company during the 3 years prior to the development of DSM-5-TR: 53 of the 86 who were panel members, and 2 of the 6 who served on the decision-making task force (6). The results had barely changed since the development of DSM-5, published in 2013, apart from a decrease in the proportion of task force members with financial links to industry, from two-thirds to one-third (2,6). The 92 doctors collectively received benefits amounting to $14 million between 2016 and 2019, before they started working on the DSM (6).

As in the earlier studies, conflicts of interest were particularly rife in diagnostic areas for which pharmaceutical companies market drugs. One-third of the financial links identified involved payments for conferences or situations in which the doctor's role was that of a "key opinion leader" (6).

The authors highlighted that such conflicts of interest compromise the reliability of the development process of this worldwide reference and can have a harmful influence on mental health care (2,6). Above all, these conflicts are liable to extend the medicalisation and pharmaceuticalisation of life, by increasing the number of psychological situations included in the DSM, and lowering diagnostic thresholds (6). The authors cite the example of how changes to the diagnostic criteria for attention deficit hyperactivity disorder in DSM-5 led to a well-documented phenomenon of overdiagnosis (4,6).

In light of this evidence of persistent industry influence over the development of the DSM, healthcare professionals who refer to this manual would do well to approach it with caution and scepticism.

References
1- Demazeux S "Qu'est-ce que le DSM? Genèse et transformations de la bible américaine de la psychiatrie" Ithaque, Paris 2013: 256 pages. Presented in Rev Prescrire 2014; 34 (364): 150.
2- Cosgrove L "Financial conflicts of interest in the DSM – a persistent problem" BMJ 2024; 384: q36, 2 pages.
3- Lane C "Shyness, how normal behavior became a sickness" Yale University Press, New Haven 2007: 272 pages. Presented in Rev Prescrire 2010; 30 (317): 230.
4- Prescrire Editorial Staff "DSM-V: madness!" Prescrire Int 2011; 20 (112): 24.
5- Prescrire Editorial Staff "DSM-5: riddled with conflicts of interest" Prescrire Int 2015; 24 (156): 4.
6- Davis LC et al. "Undisclosed financial conflicts of interest in DSM-5-TR: cross sectional analysis" BMJ 2024; 384: e076902, 7 pages.
 

 ©Prescrire 1 October 2024

Source: "DSM: still riddled with conflicts of interest" Prescrire Int 2024; 33 (263): 227. Free.

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