The DSM and conflicts of interest
A recent study published in The BMJ raises concerning questions about undisclosed payments to contributors for the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The analysis focuses specifically on members of the DSM-5-TR panels, finding that a majority had unreported financial ties to pharmaceutical and medical device firms. Most troubling is the revelation that over 70% of specialists on the neurodevelopmental disorders panel - which provides diagnostic criteria for conditions like autism - received industry money from 2016-2019.
The DSM guidelines carry tremendous influence in determining how such neurodevelopmental conditions are defined, diagnosed, and treated. The reliance on experts with industry backing risks skewing the process to expand / contract diagnoses or overstate the benefits of certain “interventions.” Yet the DSM panel members’ conflicts of interest were never publicly disclosed, undermining transparency around the revision process.
Whilst the American Psychiatric Association (APA) defends its conflict of interest safeguards, ethicists counter that such policies did little to mitigate more subtle biases among key “opinion leaders” backed by pharmaceutical funding. Moreover, the APA’s failure to report which DSM contributors had financial ties - despite having done so for the prior DSM-5 edition - falls short of ethical standards for clinical guidelines.
As patient advocacy groups have noted, true independence and objectivity should not be sacrificed when setting medical protocols that shape the care for those suffering from developmental disabilities. This study provides a sobering fact check on claims of impartiality and serves as a reminder about the insidious ways that industry relationships can infiltrate psychiatric decision-making. Clear separation from commercial interests must remain non-negotiable.
Regulatory Capture
The outsized influence of pharmaceutical funding on psychiatric expertise and practice guidelines is emblematic of a broader trend – the subtle co-opting of regulators by the very industries they oversee. This “regulatory capture” poses deep challenges for governance and democracy in capitalist societies dominated by ever-larger corporations.
The APA’s lack of transparency around conflicts of interest reveals how professional bodies can grow beholden to the same corporate interests they are tasked with impartially regulating. In an era of industry consolidation, regulators become dependent on the specialised knowledge and access provided by oligopolistic firms. Over time the worldview and priorities of regulators align with those companies, to the detriment of public accountability.
Without strict firewalls against commercial encroachment, regulatory systems grow porous and compromised. The reputational risks from periodic scandal are an acceptable cost of largely shaping the policy dialogue to reflect corporate interests and priorities. Only sustained vigilance and structural reforms can reorient regulatory agencies away from an insider mindset captured by close collaboration with industry.
The risks of regulatory capture become particularly acute in advanced, late-stage capitalist economies marked by unprecedented market concentration across pharmaceuticals, tech, finance, and other sectors. Preventing excessive corporate influence on governance, professional standards, and clinical practice guidelines should remain an urgent priority. Maintaining professional autonomy and balance serves as a bulwark for medical ethics and public health amid the profit-maximizing currents of today’s highly financialised brand of capitalism.
The effects on the autistic community - the Empire Strikes Back in DSM 5-TR
Is it just me, or is there a point to be made about the potential financial incentives behind recent changes to the DSM-5-TR criteria for autism. Given the high rates of undisclosed industry ties among experts on that neurodevelopmental panel, one must wonder whether cost considerations factored into the new tightened criteria for diagnoses.
Autism poses myriad expenses for health systems, school districts, social services agencies, and employers. The lifetime costs of supporting individuals with autism in the US are estimated at $2.4 million per person (source). With prevalence continuing to increase through DSM 5, both public and private entities face soaring outlays for “therapies,” educational interventions, and workplace accommodations.
In that context, might the revised DSM guidelines intentionally raise the bar for an autism diagnosis as a means of controlling costs? The heavy involvement of researchers and clinicians with ties to medical product firms could lend credence to suspicions of financially-motivated decision making. If the pharmaceutical industry views mounting autism rates as threatening their bottom line, a subtle narrowing of diagnostic criteria presents one way to trim patient numbers (see my previous thoughts on this here and here and here).
Of course, no specific evidence suggests experts consciously restricted the definition solely to dampen autism’s economic impact. Yet the lack of transparency around potential financial and non-financial conflicts of interest inevitably raises doubts. Without full disclosure and rigorous safeguarding of impartiality, the independence of judgement undergirding clinical guidelines gets called into question - along with public trust in those guidelines shaping patient care. This case underscores the urgency of greater separation between regulatory processes and corporate interests.