(See the previous piece on the IMMDS Review and the RCPsych’s failure to promote it)
In October 2018 Dr David Baldwin FRCPsych, appearing for the Royal College of Psychiatrists (RCPsych), provided written responses to the Review Panel’s written questions. The last of those questions (p. 214) concerned conflict of interest (COI):
It is false to claim the declarations on the RCPsych website are ‘full’ when they only go back three years. The Review is public, so the meaning of ‘full’ should be as the public would understand it, rather than professionals or academics.
And Dr Baldwin was clearly aware that the IMMDS Review is substantially ‘historical’: in his oral evidence he talked about valproate’s elevated risks being known since the mid-1990s. Therefore his answers about COI should contain information covering decades, not just a few years.
As it happens, Dr Baldwin’s current RCPsych declarations are nearly two years out of date:
Further, it is absurd to claim that these statements are ‘full’, given that they are unquantified. We actually have Dr Baldwin’s recent quantified declarations on the ABPI’s ‘Disclosure’ site:
I have never seen the RCPsych, any NHS website, or any mental health charity mention the ABPI Disclosure site, so the chances of any patient looking at it before they consult a psychiatrist seem slim. And because disclosure in UK law and GMC guidance and regulation is voluntary, these may only be part-disclosures.
I think the few patients who would look this up in advance would be more wary of psychiatrists who had not disclosed. But because of the law and the GMC’s soft approach, that information is not available.
A patient with FACS, or a relative, researching a psychiatrist who prescribed valproate to a mother, will be unable to find even this incomplete information beyond three years.
Dr Baldwin claimed the RCPsych produces ‘clear guidance’ on COI. It is not ‘clear’. Good Psychiatric Practice states that COI declarations must be made when engaging in ‘college activity’: it does not state whether such declarations should go beyond the usual three years, or whether they should be quantified. In my experience they do not and are not.
For clinical work Good Psychiatric Practice simply refers to the GMC’s Good Medical Practice: to be dealt with in a future piece here.
As for Competing Interests: Guidance for Psychiatrists, I was unable to find such a document on the RCPsych website.
In the oral evidence on 28th January 2019 it is disappointing that the IMMDS Review panel asked Dr Baldwin no questions about COI.
NHS psychiatrist Dr Peter Gordon has been campaigning for compulsory COI declaration laws for years. The RCPsych has refused to comment on the issue, stating that it is ‘a matter for the government’. The GMC failed to respond to his enquiries. In my view these are expressions of contempt towards people experiencing drug and device harms. In late 2018 Dr Gordon resigned his membership of the RCPsych and he later revealed he had been ‘gaslighted’ by the RCPsych, but that his NHS employer supported him.
Dr Gordon has documented Dr Baldwin’s long history of involvement with Pharma, including his promotion of the allegedly ‘defective’ SSRI Seroxat, and its dubious UK licence for ‘Social Anxiety Disorder’, which I recall many ordinary psychiatrists in the 1990s sceptically viewing as a Pharma construct.
It seems likely that my own campaigning on Pharma COI was a factor in my GMC-MPTS suspension, on very dubious grounds. The GMC has still not disclosed the nature of its anonymous psychiatrist investigator’s links to the RCPsych, and it has not interviewed me, seven months after it received the first anonymous complaint about me.
Dr Baldwin mentioned Dr Thomas Barnes FRCPsych, in relation to the POMH survey(s) of prescribing rates of psychiatric drugs in the NHS. Dr Barnes is a member of the psychopharmacology committee and his current COI declaration is even more out of date:
Finally (for this piece on COI), Dr Baldwin mentioned the British Association for Psychopharmacology (BAP) several times, as having views and policies on valproate in line with the RCPsych. The editor of the Journal of Psychopharmacology (BAP’s main journal) is Dr David Nutt FRCPSych. It is interesting to see that Dr Nutt’s latest paper has Dr Baldwin as a co-author. I have criticised Dr Nutt in my ‘Manifesto‘:
Dr Nutt’s recent ABPI COI voluntary declaration supports the idea that Pharma payments to doctors correlate with a ‘dismissive’ attitude towards patients experiencing drug harms:
Dr Peter Gordon (see above) has published this mildly satirical image of Dr Nutt, based on past drug company interests:
I have defended this use of satire, against the accusation that it is unfairly ‘ad hominem’.
Next week (or, possibly, the week after): Dr Baldwin’s failure to submit evidence on the range of opinion on bipolar disorder within the RCPsych, especially the opinion that milder forms of bipolar (‘bipolar 2’) have been promoted under Pharma influence.
(First in a series of 7-8 pieces on the IMMDS Review, to include the GMC, epilepsy, misogyny and other reasons for ‘dismissive’ treatment of patients and relatives concerned about drug and device harms. The pieces will be submitted as evidence, with other material.)
The Independent Medicines and Medical Devices Safety (IMMDS) Review is looking at historic and current concerns about three medical products: valproate, surgical mesh, and Primodos (a now discontinued drug to test for pregnancy).
Valproate has been widely used in bipolar affective disorder since the 1980s, and in epilepsy since the 1970s. In March 2018 it was banned in pregnancy in the UK, and throughout the EU, but it is estimated that there have been 20,000 cases of Fetal Valproate Syndrome (FVS, a 30-40% chance of neurodevelopmental problems including severe learning disability and autism, plus a 10% chance of physical abnormalities) in the UK alone.
Many campaigners have suspected that pharmaceutical industry (Pharma) influence has hindered the recognition of FVS, the provision of information to patients, and the tightening of regulation.
Core written submissions to the Review were received in December 2018, and oral hearings have ended. Further submissions are welcomed and there is currently no deadline for those. Nor is there any firm date for its publication, although the end of this year is said to be likely.
I had not heard of the IMMDS review until late April 2019, when I was contacted by FACSaware, an independent Fetal Anti-Convulsant Syndrome group which has had a leading role in regulatory changes and in obtaining the Review. They hope it will recommend the setting up of a Trust similar to Thalidomide’s; but they also want a proper Judicial Inquiry to establish historical responsibilities more clearly and to consider legal and structural reforms.
They have the support of former Health Minister Norman Lamb MP, who used the phrase ‘Hillsborough-style Inquiry’ when he gave oral evidence to the Review.
My own current (non-lawyer’s) view is that such an Inquiry might also gather evidence for Misconduct in Public Office charges against GMC staff. Blog piece(s) on that soon.
The Review panel has already noted the foot-dragging on drug and device harms by the Medical Establishment (the Royal Colleges and other professional organisations). The chair, Former Health Minister Baroness Cumberlege, has stated that past and present patients and parents should not have to take the lead on these issues.
But the Establishment’s failure to tell ordinary doctors about the IMMDS Review is yet another example of this foot-dragging. Non-establishment doctors with concerns could have submitted information anonymously, which might have informed the Review panel’s questioning of Establishment witnesses.
The Royal College of Psychiatrists (RCPsych) emails me several times a month, but did not email me about the IMMDS Review, despite the many clear links with psychiatry: bipolar disorder, epilepsy, learning disability, and autism (ADHD is also increasingly recognised as part of FACS).
Psychiatrist Dr Angelika Wieck MRCPsych (who is not on Twitter and appears not to have a blog) has a serious interest in FACS, has supported regulatory tightening, and presented on FACS at the College’s annual conference in 2018. The RCPsych Tweeted several points from her talk, but none mentioned the Review which had been announced four months earlier.
A recent three-page editorial on valproate in the British Journal of Psychiatry, which is wholly owned by the RCPsych, failed to mention the IMMDS Review. It talked vaguely of ‘the market’ being a factor in the overuse of valproate, rather than the Pharma-influenced behaviour of psychiatrists working in clinical practice, academic research, regulatory bodies, and directly for Pharma itself.
The BJPsych Bulletin regularly contains articles on current policy and practice: again, nothing.
The RCPsych has not posted any IMMDS information on its website or issued any statement. It has not Tweeted at all:
All this indicates that RCPsych leaders do not want ordinary or dissident psychiatrists submitting their own evidence to the Review. And it conforms to a well-established pattern of closing down discussion of drug harms, and conflicts of interests, wherever possible.
Part 2 (Wednesday): the evidence submitted by Dr David Baldwin FRCPsych, chair of the RCPsych Psychopharmacology Committee, and senior British Association for Psychopharmacology member. Plus the questioning of him by the panel on 28th January 2019.
A recent study from Sweden, published in the British Journal of Psychiatry (1), appears to confirm a link between high ability and bipolar disorder. Over seven hundred thousand teenagers were followed up to see if they were admitted to psychiatric hospital in their twenties and thirties. Then their school examination grades at 16 years were compared with those of the other students who had not developed such severe mental and behavioural problems.
The adults with bipolar disorder had done better in exams as teenagers, especially in humanities subjects such as Swedish and History (but not Art). Those who had been good at Sport seemed to have a lower chance of developing bipolar disorder later.
This is an interesting study which is in keeping with the suggested link between bipolar disorder and creative ability. However, it does not mention the possibility that adult ADD / ADHD, which also can sometimes lead to hospital admission, may have been the real problem in many cases. Like much research of this kind, the diagnosis was made a long time ago (1988 – 1997), when there was even more scepticism about adult ADD / ADHD than there is now (2).
(1) Excellent school performance at age 16 and risk of adult bipolar disorder: national cohort study. http://bjp.rcpsych.org/cgi/content/abstract/196/2/109
(2) For an example of how creative ability may be linked to ADD / ADHD, see my Blog piece on Vincent Van Gogh: https://drnmblog.wordpress.com/2010/02/05/vincent-van-gogh-did-he-have-add-adhd/
Unlike the BBC’s Panorama (1), The British Medical Journal (BMJ) gives space to a wide range of views on mental health and behavioural disorders. An article on adult ADD / ADHD last week is an example of how polarized debates can become. One side repeated, as fact, Panorama’s “unfair and not open-minded” opinion on the poor long-term outcome for medication in ADD / ADHD (2).
The BMJ published my own comment online (3), pointing out the need to test and monitor new nurse-led adult ADD / ADHD diagnosis and treatment (4). Of course, the Department of Health is quite right to look for the most cost-effective ways of delivering services, and nurses bring their own distinct and valuable skills to a wide range of clinical settings. But I have already had two conversations with specialist NHS nurses working with children and teenagers, who were concerned at being pushed into taking on too much responsibility too soon.
“Critical Psychiatry” is generally skeptical about all “medicalisation” of problem emotions and behavior. So it seems a bit odd to me that the authors of this piece attacking adult ADD / ADHD suggest that “more established diagnoses…depression, anxiety, and modern conceptions of bipolar and bipolar spectrum disorder” be kept in preference.
This does, though, raise a further question about clinical specialists. Why should adults with “non-established” ADD / ADHD have less direct access to NHS psychiatrists and clinical psychologists, than people with “established” conditions? Surely it is more logical that they have more?
(1) See my last two Blog postings