I would like to examine several possible sources of increased revenue for the APA, which could be used to prevent a cut back of the Assembly and the Components, as well allow for consideration of developing new important programs.

Dues Increase

If the membership wishes increased services, they should be willing to consider paying directly for them. The national dues have not been increased for several years. There are different categories of membership, which have different levels annual dues. If the dues are increased an average of $50 / member over a five year periods, this would gradually increase the income starting with $380,000 the first year. At the end of the five year period the APA  income would be increased $1.9 million /year. Of course, there is the possibility that some small percentage of the 38,000 members would drop out because of the dues increase. On the other hand, if new exciting activities were developed as described below, we could increase membership. A conservative estimate would put this at an average of $500,000/year

How to Use Profits From DSM V

The APA has made an arrangement with APPI so for DSM V the APA will own the rights to DSM V when it comes out in 2011. I understand the previous performance of DSM IV cannot reliably predict the profits from DSM V. However, we still can anticipate this book will be used worldwide as will the accompanying texts which will be published. Most mental health professionals, institutions, government agencies, attorneys, etc  will want to own a hard copy of it, even though there is a trend to looking things up on the Internet. I also assume that there will be DVD versions of it which will be sold. On the basis of some discussions I had  with people who know something about these things,  I would predict that the APA can anticipate a profit of $10 million over the next 8-10 year for this product. This would be a conservative estimate. Therefore if half the proceeds were put into the APA  reserves that would allow another $500,000/year available for the APA budget.

APA Foundation Could Take Over Significant Part of Public Affairs

The APA Foundation is suppose to be 100% in sync with the APA and certainly shares the same goals and aspiration for mental health and education of the public, increasing public awareness and raising money to do good projects for mental health. It is only because of some technical, legal issues related to taxes that there are separate Boards of the APA and the Foundation . There are efforts being made to allow these organizations to function more in unison in the future. As I mentioned in a previous blog, I believe, the forced reduction of the Communications Component has seriously taken away many opportunities for public affairs programs. I therefore suggest that the Foundation should appoint staff consultants who are very familiar with the previous APA public affairs program as well as the current ones . They should use the resources of the Foundation  to run national, state and  local public affairs programs as a major initiative. They can run a Public Affairs Institute, advise and assist mental health advocates from various District Branches write letters to the editor, run educational training for psychiatrists  etc. They can liaison with the APA while still keeping their independence, if that is necessary. They can take over some of the spending in public affairs that have been in the APA budget. I would estimate that this could easily result in a savings for the APA of at least $200,000/year without any loss in the quality of public affairs for mental health and American Psychiatry.

APPI Should Use APA District Branches as a Commissioned Sales Force

APPI was originally developed as an arm of the APA, which was expected to serve a completely dedicated to the APA mission. It has become the most successful publisher of psychiatric books in the world. Even after having sold the rights of DSM back to the APA they still should be able to make considerable profits. Although there is still that problem of having separate Boards although appointed by the Medical Director of the APA, they should be interested in doing everything possible to support the APA. Every publisher makes arrangements with sales teams to take their books into a particular setting, make sales and then pays them a commission. I propose that each District Branch should become a commissioned sales representative for APPI. They should include APPI advertisement for APPI books in all their mailing with special discounts as well as promoting books at all meetings and activities. District Branch members should be aware that buying their books through the District Branch would allow their DBs to receive significant commissions. Once it is determined how much money the DBs are receiving, a certain percentage of APA support or revenue sharing from the Assembly budget being given the DBs should be reduced. The net result should be increased funding for the DBs and decreased support from the APA to the DBs. It might turn out that APPI might make less of a profit but they would be serving their overall mission to support the APA. There would be an incentive for the DBs to promote APPI books and products which could include sales to the local mental health community who they know best as well as the public in their area. These activities might even drive up APPI profits.  I estimate the APA could save at least $100,000/ year by this method.

Use of State of the Art Video Communication

I know that the APA has made great strides in introducing some video communications and have encouraged the use of conference calls, webinar and perhaps Skype meetings. I personally believe that face to face in person meetings should not be completely eliminated and that the combination of at least one face to face meeting combined with state of the art video/personal computer conferencing is now feasible.  I would suggest that the APA become very aggressive in advocating such communications for at least some percentage of most committee meeting including, as an example, of at  least one Board of Trustees meeting. The savings in hotel, travel, food can make a considerable savings for the APA. One would almost think that the members should contribute to buying their equipment own since they would save time away from practice. However, I believe that an investment by the APA in providing equipment in the short and long  run would save the APA money. I would suggest that the APA could save at least $50,000/year.

APA Needs to Go Global

I have saved my most ambitious proposal for last. I am convinced from what I see happening in the economy, business and in the various activities of so many people that I know, that our lives are becoming more global in every way. I believe that the APA has to begin to take significant steps to become a global (still American) organization.  We need to look at every aspect of our organization and see how we can become more global.

Starting with membership, we should offer a membership category to international members at a reduced cost  (to cover journals , mailings etc plus enough to make a profit for the APA). This lower rate should be contingent on the international members being a member of their own national psychiatric organization or the World Psychiatric Association.. This way we won’t compete with international organizations but would allow them to encourage membership as global members of the APA. Obviously we will need to provide international members with special benefits such as discounts of APPI books, facilitated access to disaster materials, perhaps some special online or Skype CME courses. As part of our efforts to go global, the newly invigorated Assembly (with some increased funding) should have a certain number of international delegates to the Assembly perhaps one from each country or from each major area of the world for a start. Oh yes, the APA Assembly should be broadcast live online (as well as being archived) so our members in the US and all over the world can see American psychiatry in action. While we are doing this we should set up electronic voting which I unsuccessfully advocated for when I was Speaker of the APA Assembly – the price has come down and we do need to showcase the fantastic democratic methods we use in the Assembly when we broadcast the proceedings around the world. I estimate over the next five years we should be able to add at least 1000 global members – so lets figure in the long run we add at least another $100,000 /year income after added expenses are taken into account.

How It All Adds Up

I realize that I am letting my imagination get a little carried away. I tried to build these ideas on facts and speculation that has good foundation. I may be wrong in some of my calculations or may be a little ahead of my time (or perhaps behind if some of these things are being contemplated already). However I tried to be conservative in my estimates and I came up with almost  $1.5 million dollars/year available for reinvigorating  the Assembly and reestablishing the Components in a responsible manner.  I am also suggesting that there may be innovative approaches to increasing available funding.  I encourage our members and leadership to continue to look for newer and better ways of doing things for our patients and our profession.

The first new draft of the Diagnostic Statistical Manual 5th edition ( DSM V) has been released and is available online for review and for comments by psychiatrists and any other interested persons.. This is the book that is used world wide to define and describe mental disorders. The final product will come out after further revision and is scheduled for publication in  2012. The process of preparing this massive undertaking, although not without some controversy, has really been quite remarkable.

Remarkable Preparation Process

I had an inside of view of the efforts to make this a balanced fair non prejudiced process as I was on the Board of Trustees of the American Psychiatric  Association for two years during my term as Speaker of the Assembly. The leadership and the various committee chairs and members of subcommittees were chosen very carefully not only to pick the people with the best expertise but also with extraordinary efforts to examine that they did not have any outside vested interests which could interfere with this process.

In addition efforts were made to balance the choices among equally outstanding experts to be sure that various underrepresented groups including women and minorities were properly represented. The multiyear process of studying and examining the diagnostic categories also included authorizing and supporting various research projects such as  multi-centered field trials conducted across the country. The study of mental disorders can’t be done in a test tube but nevertheless great efforts were made to use the scientific method of randomized double blind studies whenever possible to draw valid conclusions.

There also was a special Gender and Cross-Cultural Group which reviewed the data from various countries and cultures as well as the emerging DSM V. They did not find any evidence of bias in the diagnostic criteria.

Preliminary Draft is Presented Online for Comments

The presentation of the new findings, which as mentioned, is still subject to some change depending on the comments and any new data which becomes available. The information about the proposed DSM V is presented online in a clear understandable manner despite the complexity of the overall process.

There are four online buttons, which will offer information on each diagnostic entity. They are as follows:

1. Existing DSM IV -The current  diagnostic nomenclature and descriptions are presented.

2. Proposed Revision DSM V changes of currently listed diagnosis and criteria  including a description of any new ones. Not all were changed.

3. Rationale used for new diagnosis or for revision of old one. This might include a discussion of the perceived clinical needs for this new listing or for the revision of the old one. It also  presents the research on which the decisions which led to this change were based .

4. Severity- A method for evaluating the severity of  various conditions was presented often using a scale which had been tested for a particular diagnosis.

A Few Examples of New Changes in DSM V

Those interested in a particular diagnostic category  will want to examine that section of the proposed DSM V in detail. I will comment on four components at this time

Mulitaxial Categories Will Be Changed

It is being recommended that Axes I, II, and III  of the current system be changed into one axis that contains all psychiatric and general medical diagnoses whereas previously psychiatric disorders, personality disorders and medical  conditions were all listed separately. Axis IV is currently where clinicians document psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. The exact form of this axis is still under consideration with the hope to make it closely method used in the World Health Organization  (WHO) International Family of Classifications known as ICD 10 , Similarly the current Axis V which allows clinicians to rate a patient’s overall level of functioning will probably end up using  the above system in which disorders and their associated disabilities are conceptually distinct and assessed separately

Subtypes of Schizophrenia Eliminated

No longer will the term schizophrenia  paranoid type be used. In fact all the subtypes of schizophrenia have been dropped  based on studies which showed that the value of using subypes were unfounded. Instead schizophrenia would be defined based on the presence of delusions, hallucinations , disorganization, and abnormalities in speech and psychomotor behavior as well as the presence of negative symptoms such as restricted affect. The presence of paranoia would be described under delusions  as would  the other previous subtypes would be used in the appropriate criteria category. There also was a new category called Psychosis Risk Syndrome which is based on the research, which showed certain symptoms, and behavior could be identified in young people and therefore treated which might prevent the development of schizophrenia. This change might encourage innovative important treatment but some people are concerned that this  new category might label (or stigmatize) young people who would not develop this major psychiatric disorder.

Changing Bipolar Disorder Criteria in Children

There would be a new childhood condition  called Temper Dysregulation Disorders with Dysphoria. . This would encompass aggressive irritable children who have been given diagnosis of Bipolar Disorder and did not turn out to have this disorder as they grew older. Many people have been concerned that such children unnecessarily received antipsychotic drugs, which cause weight gain, and metabolic changes that could have been harmful to them

Asperger Disorder Eliminated.

The diagnostic category of Autism Spectrum Disorder  will encompass what was previously called Asperger Disorder. Many clinicians had been doing this already for the past few years. Studies have shown that the old term was used loosely with little agreement as to specific criteria. Previously defined autism and Asperger Syndrome were found to occur in the same families although there still is no clear evidence of the cause of them . The new proposed criteria for Autism Spectrum Disorder will have clear criteria for the dimensions of severity that include language functioning and intellectual level or disability. The writers of the proposed DSM V recognize that there may be some individuals with subclinical features of this condition who may want to use the term ‘Asperger Disorder’ to understand themselves better or a doctor to understand a patient when comparing a patient to the old literature or  case reports  which used the terms Asperger Type or Kanner Type.

DSM V Proposal Welcomes Comments

There is a lot more to digest than I have touched upon in this piece. The authors of DSMV have put a tremendous amount of work in this project. It will not be issued until next year. There is still time to make comments and suggestions. Not only must this readjustment of diagnostic categories and criteria be useful for future research but it must meet the needs of the clinicians who are working with patients on an everyday basis. I hope all interested parties will review the  the current draft and send any comments or  suggestions to  the DSM V website ( prior to their April 20^th deadline )  as well as commenting here.