as well, wherein all found that approximately 60% of women with pmdd in the trials improved with the drug; representatives from lilly & co. and the fda participated in the discussion. various strong stances were taken in said discussion. sally severino, a psychiatrist, argued that because symptoms were more prevalent in the united states, pmdd was a culture-bound syndrome and not a biological condition; she also claimed it unnecessarily pathologized the hormonal changes of the menstrual cycle. jean endicott, another psychiatrist and chair of the committee, has argued that it was a valid condition from which women suffer and should be diagnosed and treated, and has claimed that if the symptoms were felt by males, far more effort and research would have been done by that moment. in the end the committee kept pmdd in the appendix. the decision has been criticized as being driven by lilly's financial interests, and possibly by financial interests of members of the committee who had received funding from lilly. paula caplan, a psychologist who had served on the committee for the dsm-iv, noted at the time of the dsm-iv-tr decision that there was evidence that calcium supplements could treat pmdd but the committee gave it no attention. she had also claimed that the diagnostic category is harmful to women with pmdd, leading them to believe they are mentally ill, and potentially leading others to mistrust them in situations as important as job promotions or child custody cases. she has called pmdd a fake disorder. nada stotland has expressed concern that women with pmdd may actually have a more serious condition like major depressive disorder or may be facing difficult circumstances—such domestic abuse—and therefore may have their true issues remain undiagnosed and mismanaged if their gynecologist diagnoses them with pmdd and gives them drugs to treat it. the validity of pmdd was once more heavily debated when it came time to create the dsm-5 in 2008. in the end it was moved out of the appendix and into the main text as a formal category. a review in the journal of clinical psychiatry published in 2014 examined the arguments against inclusion, which it summarized as: the pmdd label will harm women economically, politically, legally, and domestically; there is no equivalent hormone-based medical label for males; the research on pmdd is faulty; pmdd is a culture-bound condition; pmdd is due to situational, rather than biological, factors; and pmdd was fabricated by pharmaceutical companies for financial gain. each argument was addressed and researchers found: no evidence of harm; no equivalent hormone-driven disorder has been discovered in men despite research seeking it; the research base has matured and many more reputable studies have been performed; several cases of pmdd have been reported or identified; a small minority of women do have the condition; and while there has been financial conflict of interest, it has not made the available research unusable. it concluded that women have historically been under-treated and told that they were making their symptoms up, and that the formal diagnostic criteria would spur more funding, research, diagnosis and treatment for women with pmdd.