APA Threatens to Sue "dsm5watch" Website

I just read Bernard Carroll's interesting post on the Health Care Renewal Blog about the latest DSM-5 brouhaha. It appears that the American Psychiatric Association has sent a "cease and desist" letter to a website critical of the DSM-5. The site was called "dsm5watch," but the APA argues that using DSM-5 in the blog title is an infringement of their trademark. The owner of the blog, Suzy Chapman, having no funds to tussle with APA lawyers, simply changed the name of her site to dxrevisionwatch, which, she says, has resulted in much less traffic.

Is the APA simply protecting its ownership of a lucrative franchise, or is it engaging in something more insidious, what Dr. Carroll calls the "SLAPP maneuver," an acronym for "strategic lawsuit against public participation"? I'm guessing that APA would have had little problem with the site if it were cheerleading the DSM-5 process. It all seems rather heavy-handed to me. After all, the New York Times appears to have no problem with the anti-Times site called TimesWatch. In a democratic society, healthy dissent and debate is part of the package. It may be annoying, but that doesn't excuse the bullying tactics that the APA has chosen.

The APA, Power, and the Exclusion of Dissent

Dr. Doug Bremner has a fascinating but unsettling post about colleagues disinviting him to co-author an academic paper, because they were upset by this blog post he had written.

I have no idea how deep this issue goes, and there is always more to everything than meets the eye, but I do have my own recent personal experience of being shunned by the academic establishment, and I thought this would be an opportune time to tell that story.

As some of you know, in 2008 I was elected by those liberal Massachusetts psychiatrists to be one of four state representatives to the American Psychiatric Association. This means that I attend monthly meetings of the council of the Massachusetts Psychiatric Society, as well as quarterly meetings of the New England region (called “Area 1”) of the APA.

One of the things that happens when you get into a leadership position in a big organization is that you find out that there are dozens of committees and task forces and this is where all the real work takes place. Sometimes you get appointed by a powerful person, like former president Nada Stotland, who appointed me to a couple of committees, one of which was the task force leading to the APA’s decision to phase out industry supported CME at the annual meeting. Other times, you end up in committees via informal protocol.

Thus, for example, if you are on one of the APA Area councils (which I am), you may be invited to serve as an “Area council liaison” to a given committee. One of these committees is the “APA Steering Committee on Practice Guidelines.” As you can see here, this committee is composed of about 24 people, seven of whom are liaisons from each of the seven Areas of the APA. It’s an important committee, because it is in charge of reviewing and approving any new practice guidelines. The practice guidelines then filter their way out into the community of mental health professionals and influence how patients are treated.

Recently, my Canadian colleague Joseph Berger announced that at some point over the next year, he would be replaced on the Area 1 committee by one of his colleague, and that therefore his slot on the Practice Guidelines Committee would be open. I expressed an interest in it, because sifting through practice guidelines and the research upon which they are based is basically what I do for a living as the editor of The Carlat Psychiatry Report. Dr. Berger was happy to find an eager volunteer, and he graciously made some email introductions to the various players involved.

Here’s where things began to go sour. I heard through this or that grapevine that some of the practice guidelines committee members were concerned about my “conflicts of interest.” I was surprised, since a recent study had found that 90% of members of three major work groups of the committee had conflicts of interests (COIs) with pharmaceutical companies.

Obviously, COIs per se are not forbidden. But perhaps I represented a special case, because, while I have no drug industry relationships, I publish what might be considered a competing publication. Perhaps they were concerned that I would spy on their process to improve The Carlat Psychiatry Report.

But I found out that the concern was about something else entirely. Somebody on the committee said that I had embarrassed members of the DSM-V committee by publishing something on my blog. I wracked my brain for what this could be. Finally, while on my morning jog, it came to me.

Back in October of 2008, I posted this article reviewing the breaking news about the extent of Dr. Charles Nemeroff’s undisclosed conflicts of interest at Emory. There were almost 30 comments on that posting, and one of the commenters, who was anonymous, left the following comment:

“A reminder that a further feature of pseudoacademic pseudopsychiatry is that the group noted by Dr. Gitlow defines the diagnoses we use, and defines them of course in a way that not only maximizes drug treatment, but shapes them according to the interests of particular drug corporations. One recent example only: Dr. Schatzberg has been campaigning at the APA DSM V committee meetings to dilute the criteria for major depression with psychotic features, so that the drug his company manufactures for the condition might attain broader use.
October 5, 2008 8:17 PM”

I confess that I don’t scrutinize every single one of the comments that are left on my blog. I publish just about any comment that comes in, as long as it is not profane or completely off-topic, and I make no guarantee that comments are accurate. I also often disagree vehemently with commenters. That’s called healthy debate.

At any rate, somebody in the higher APA echelons saw this comment, and I was told that it inaccurate, and that my publishing it reflected poorly on both myself and on the APA.
While under no legal obligation to do so, in order to soothe hurt feelings, I decided to delete the comment, and announced the fact in this post.

Well, no good deed goes unpunished, and somebody on the practice guidelines committee is still sore about the incident and believes this shows I am a loose cannon and that my presence would inhibit free discussion on the guidelines committee.

Actualy, if anything, I would think that the presence of someone who has been at the forefront of ethics reform efforts would help to legitimize and improve the APA guidelines process.

The episode is profoundly disappointing to me personally, because I have a particular interest in making the currently dry guidelines more readable and therefore more likely to be read by practicing psychiatrists.

But it is also disappointing to me as a member of the APA, because I would have thought that the tent of the organization is big enough to tolerate the rubbing of shoulders between people who may disagree strongly on some topics. Psychiatrists, of all professionals, should know that avoiding confrontation is rarely the road toward health, whether psychological or organizational.

The APA and Drug Money: We're on it, Senator!

Senator Charles Grassley recently sent a letter to the American Psychiatric Association (APA) requesting detailed information on all of the organization's financing from drug companies. This received extensive coverage in the New York Times, as well as other media outlets. For those interested, the APA sent out this email to its membership about the issue (reproduced on Pharmalot--scroll down on their site to see it).

I find myself in the unfamiliar position of being an APA insider regarding this issue. I was appointed by the current APA president, Dr. Stotland, to the work group she alludes to in the Times article. I announced this work group in a prior post. It was formed in March, and its official mission is:

"The formation of an ad hoc work group of the Board [meaning the Board of Trustees] charged to work with the Medical Director to: identify the categories and amounts of monies received from the pharmaceutical and other industries producing products or services used in psychiatry by the APA and its subsidiaries; determine what direct and indirect financial consequences there would be from discontinuing each category; indicate how the APA could adapt to the attendant change in revenue; and to provide the Board with the elements of a 5 year plan to end or diminish the pharmaceutical revenue received by the APA. The ad hoc work group will report to the BOT with a report and recommendations by October 2008."

So, in defense of the APA, they were already getting quite serious about examining the influence of the pharmaceutical industry well before Grassley's letter. All members of this work group were asked to sign a confidentiality agreement as a condition of participation. I thought long and hard before signing, and ultimately decided that I could be more helpful to the cause of honesty and transparency in the APA by signing and participating than by walking away.

Therefore, I can't reveal any specifics of the work group's discussions. But more generally, I can say that I have been impressed by the thoughtfulness of the discourse. Everybody realizes that this issue is a serious one for the organization, and some sincere, determined work has gone into the deliberations thus far.

Meanwhile, on a related note, over at the arch-conservative pharma-funded site, Drug Wonks, Robert Goldberg rants about Grassley's "obsessions," using the tired and worn out argument that since Grassley himself receives money from companies (imagine, a U.S. Senator receiving campaign contributions from companies and lobbyists, how shocking) he has no business calling the APA or anybody else on the carpet about their finances. Of course, the issue is less the money itself, but rather the need for transparency. The next time somebody feels the need to call Grassley or anybody else a hypocrite, I suggest you check out the Open Secrets website. Here, can read all the financial details you can stomach of anyone in the Congress or the Senate. Not only are legislators required by law to reveal the amounts and sources of all campaign contributions, but they must also reveal everything about their personal finances. Physicians have it a little easier than this.

From Embarrassment to Scandal: Lilly + APA + The Psychiatrist's Program + Lots and Lots of Money

What began as an embarrassment of Eli Lilly, PV Updates, and PRMS is gradually becoming a full-fledged scandal. The Indianapolis Star picked up the story last weekend (read it here), and psychiatrist David Port, M.D. wrote me a letter alerting me to an expanding crisis of trust in psychiatry. Here is an excerpt:

"Whatever Lilly's justification for sponsoring a course ostensibly to help the psychiatrist to better deal with professional liability risks, I am outraged that PRMS has accepted money from Lilly and has chosen to offer its authority and reputation toward this Lilly effort. PRMS is the American Psychiatric Association-endorsed entity which directs APA members to a selected malpractice insurance agency. PRMS is thus the agency many or most of us psychiatrists turn to for guidance and direction as to liability exposure and malpractice coverage. For PRMS to work for Eli Lilly is a glaring conflict of interest between their psychiatrist clients and a pharmaceutical corporation whose interests do not necessarily coincide with those of the psychiatrists with whom they have a professional relationship. This is analogous to the same law firm representing two individuals opposing one another in a law suit; in that situation we assume that there cannot be fair representation of either client, and we may imagine that the client with an attorney who has more clout in the law firm may well prevail in the action. How can we trust PRMS, or the APA for that matter, to provide us with the best liability support? David Port, M.D."

Yes, it's true. PRMS runs The Psychiatrist's Program, a malpractice carrier that is officially endorsed by the APA.

I know, it can get very confusing. Let's follow the money. Eli Lilly gives the APA at least $1.3 million in 2007 (so far) for industry-supported symposia and fellowships. Lilly then gives PRMS a bunch of money (Lilly refused to tell John Russell at the Indy Star how much) to produce a web-based slide show teaching psychiatrists how to prescribe potentially toxic medications like Zyprexa without being sued. The APA officially endorses PRMS' psychiatry malpractice insurance for its members. Does APA receive any type of kickback for this endorsement? I assume that would be illegal, but who knows?

Look, I get as annoyed by conspiracy theorists as the next guy. But the web of money and influence here is so murky and repugnant that it leaves me wondering what's going on. I officially invite both the APA and PRMS to respond. And I'd love another diplomatic letter from Eli Lilly!