Tuesday, July 14, 2009

Resignation Letter to DSM-V Workgroup

Dr Jane Costello, PhD, professor in the department of psychiatry and behavioral sciences at Duke University and former DSM-V Workgroup member resigned from the Child and Adolescent Workgroup in March after feeling that the development of the new edition was off-track. Dr Costello shared the letter she sent to Workgroup leader, Danny Pine, MD (NIMH). A copy of the letter she sent follows.

Dear Danny;
As we discussed at the DSM-V meeting last week,
I am resigning from the Child and Adolescent Disorders workgroup. As you know, I
have been thinking about this for some time, but have been reluctant to take
this step because I very much enjoy working with this extraordinary group of
people, and learning so much from them. However, I cannot in good conscience
continue. These are my reasons:

1. I am increasingly uncomfortable with the
whole underlying principle of rewriting the entire psychiatric taxonomy at one
time. I am not aware of any other branch of medicine that does anything like
this. (The ICD revisions make no attempt to rewrite the details of each
diagnosis.) There seems to be no good scientific justification for doing this,
and certainly none for doing it in 2012.

2. When we began this process, we
agreed that changes would only be made if there were empirical evidence to
support them. Sometimes (as with Charlie’s [Charles Zeanah, MD, Tulane
University] work on preschool PTSD) this has been the case. But as time has gone
by, the gap between what we need to know in order to make revisions and what we
do know has grown wider and wider, while the time to fill these gaps is
shrinking rapidly. More and more, changes seem to be made for reasons that have
little basis in new scientific findings or organized clinical or epidemiological

3. Efforts by Pat Cohen [Patricia Cohen, Ph.D., Columbia University]
and myself in 2007 to provide data to fill some of the gaps in the knowledge
base were rejected. One reason given by David [David Kupfer, MD, Univeristy of
Pittsburgh] was that the answers to questions were needed within 6 months, i.e.,
by the end of 2007. Now Prudence’s [Prudence Fisher, Ph.D., Columbia University]
grant has a favorable review and may be funded by the fall of 2009, with data
available perhaps in 2010. As far as I am aware there is not yet a process in
place for feeding to Prudence the questions that the data sets could be used to
answer, so any results are likely to be even more delayed. This, as we have all
agreed, makes no sense.

4. One reason why it took so long to get a data base in
place was that a decision was made that the work had to be done via a grant
application to NIMH, with all the time delays entailed by that process. The
reason given was that the funding allocated by the APA for research for DSM-V
was not enough to support the necessary work. I continue to be shocked that the
APA would even consider revising the DSM without being willing to allocate the
funding necessary to carry out the underlying scientific studies. A drug company
that tried to bring a product to market on the basis of inadequately-funded
research would rightly be censured. This is what the APA is doing, and now that
it is quite clear what is happening I am afraid that I cannot bring myself to be
part of the process any longer.

5. The tipping point for me was the memo from
David and Darrel [Darrel Regier, MD, American Psychiatric Association] on
February 18, 2009, stating “Thus, we have decided that one if not the major
difference between DSM-IV and DSM-V will be the more prominent use of
dimensional measures in DSM-V”, and going on to introduce an Instrument
Assessment Study Group that will advise workgroups on the choice of old scale
measures or the creation of new ones. Setting aside the question of who
“decided”, on what grounds, anyone with any experience of instrument development
knows that what they proposed last month is a huge task, and a very expensive
one. The possibility of doing a psychometrically careful and responsible job
given the time and resources available is remote, while to do anything less is

It has taken me a long time to reach this conclusion,
largely because I greatly value and enjoy working with you and the workgroup,
and respect your commitment to the DSM-V process. I honor your position – that
given DSM-V is going to be written, the best people should do it. You know that,
as always, I am ready, as in the past, to carry out any data analyses that could
be helpful to your decision-making on specific issues. Please give my greetings
to the rest of the workgroup, and feel free to share with them as much of this
as you choose.

1 comment:

  1. I started "boning up" on DSM V progress just today. I'm close to retirement and writing a book that deals with (past) psychiatric diagnosis so the operational details of DSM V have been less on my mind than the conceptual issues. However, the controversy that has erupted in coincidence with the launching of field trials this month in order to meet a 2012 publication date should give caution to anybody who expects the new DSM to be an improvemnt on the old. I spent 10 years in practice after over 20 years in academics, and I am persuaded that the issues boil down to two old freinds - academic arrogance and money. Why didn't the NIH fund these efforts more adequately? Could it be that either the issues raised were not signficant enough to warrant the expense of investigation or was the experiental design to test hypotheses directly not shown (I suspect the latter as there has been almost nothing published in 15 years that would argue for major changes). After all the time that has elapsed a single year does not seem likely to provide time to collect and analyze data that would support any major changes. It sounds like V could be IV plus symptoms rating scales. Whatever the conflicts of interest and contromizes of the editors past and present may be,the APA which represents American Psychiatry clearly has a overriding financial interest in this,and will be putting a final imprimatur on DSMV one way or another. It would be best to intervene now,to call a truce, hopefully go back to the drawing board, and bring in a more representative sample of American psychiary before going ahead with a project that sounds suspciously like the high priced bird that somebody sold to Little Abner which flew so fast that no body could see it.