DSM: who wrote it, and with what ties

The 69% — and why it does not mean an increase

Lisa Cosgrove and Sheldon Krimsky reported that 69% of the 29 members of the DSM-5 task force — about 20 people — disclosed financial ties to the pharmaceutical industry under the APA's new mandatory disclosure policy. That policy did not prohibit ties: it capped them at US$10,000 a year in industry income and US$50,000 in pharmaceutical stock.

By work group: Mood Disorders 67% (N=12), Psychotic Disorders 83% (N=12), Sleep/Wake Disorders 100% (N=7).

What it does not establish. Because DSM-IV carried no mandatory disclosure and its figure was reconstructed by outside screening, the comparison between the two editions cannot establish that ties increased. APA President John Oldham raised exactly this objection in March 2012 and stated that more than 70% of DSM-5 work-group members disclosed no industry ties.

[22] Cosgrove L, Krimsky S. PLoS Med 2012;9(3):e1001190, DOI 10.1371/journal.pmed.1001190

Before that: 95 of 170, and two panels in their entirety

In 2006, Cosgrove, Krimsky, Vijayaraghavan and Schneider screened publicly available records and found that 95 of 170 members of the DSM-IV and DSM-IV-TR panels (56%) had at least one financial association with industry. Research funding 42%, consultancies 22%, speakers' bureaux 16%.

Every member of the two panels covering mood disorders and psychotic disorders had at least one such tie. Both panels were small — we will not publish that as a percentage until the exact membership counts are read from the paper's own table.

The study establishes association, not causation. Its authors could not determine whether any tie preceded or followed an appointment. The question has not closed: in 2024 the BMJ published an analysis of undisclosed conflicts of interest in DSM-5-TR.

[21] Cosgrove L et al., Psychother Psychosom 2006;75(3):154-160, DOI 10.1159/000091772 · [23] Davis LC et al., BMJ 2024;384:e076902

How often two clinicians agree

The DSM-5 field trials tested how often two clinicians, interviewing the same patient independently on separate occasions in ordinary clinical settings, reached the same diagnosis. Of 23 diagnoses with adequate samples, the investigators rated, on their own published scale: 5 very good, 9 good, 6 questionable, 3 unacceptable.

We do not quote specific kappa values: the table containing them sits behind a barrier we could not pass, and we do not publish numbers we have not read.

And a chronological correction that matters: the defence of how those values should be interpreted, by Kraemer and colleagues, was published in January 2012, a year before the results — it was a pre-specified standard, not a post-hoc apology. Several of its authors went on to co-author the results paper judged against it. Spitzer, Williams and Endicott objected in a letter.

And "kappa 0.28 means a coin flip" is wrong. Kappa is not a percentage of agreement; it does not translate into "50%". Anyone who says it that way has not read the definition.

[24] Regier DA et al., Am J Psychiatry 2013;170(1):59-70 · [25] Kraemer HC et al., editorial, January 2012

When grief became diagnosable

DSM-IV barred a diagnosis of major depressive episode where symptoms lasted less than two months after the death of a loved one. DSM-5 dropped that rule and replaced it with a footnote directing clinicians to distinguish: in grief, painful feelings arrive in waves intermixed with positive memories and self-esteem is usually preserved; in depression, mood is near-constantly negative, accompanied by worthlessness.

The APA's stated reasons — quoted because they are reasonable: two months wrongly implied that bereavement lasts two months, when the usual duration is one to two years; and bereavement-related depression resembles other depression in family history, genetic influence, comorbidity, chronicity and treatment response.

The change remains among the most disputed in DSM-5. It is presented here as a decision with a stated rationale, not as a scandal.

[26] American Psychiatric Association, "Highlights of Changes from DSM-IV-TR to DSM-5", Bereavement Exclusion section

And a correction: most countries do not code on the DSM

Neither Greece nor Italy uses the DSM as the official instrument for diagnostic coding or reimbursement. Both use the ICD family, as does essentially every national health system.

Italy still codes hospital discharges and DRG reimbursement on the Italian translation of ICD-9-CM, 2007 version, in force since 1 January 2009. Greece established ICD-10-GrM by ministerial decision in 2018, initially only for hospitals piloting the Sy.K.N.Y. costing system.

The Seventy-second World Health Assembly adopted ICD-11 in May 2019, to come into effect on 1 January 2022 — but the same resolution provides transitional arrangements for at least five years, so that member states can keep reporting statistics under previous revisions.

The practical point: a dispute about the DSM is not automatically a dispute about what is written in your file.

[29] WHA72.15, 28.05.2019 · [30] Greek ministerial decision establishing ICD-10-GrM (2018)