Archive | Depression RSS for this section

Seroxat on trial again, in 2019

I first mentioned Seroxat (generic name paroxetine, US brand name Paxil) as an example of a problematic psychiatric drug in 2011. More recently, it appeared in my pieces on Dr David Baldwin’s resignation from the ‘Prescribed Drug Dependence Enquiry’, and the ‘Prescribed Harm ‘Manifesto”.

Its developers GlaxoSmithKline (GSK), who still own these brand names for the patent-expired drug, are listed for a civil trial in London’s High Court, to start on Monday 29th April and projected to last eleven weeks:

2019-04-26_Queen's_Bench_Division_daily_cause_list

For lawyers the trial is interesting because the judge who has case managed it since 2015, but will not actually be sitting, increased the financial liability of the hundred or so claimants’ ‘litigation funders’, in the event of the case being lost (perhaps this means that the funders will receive a greater proportion of the claimants’ damages if they win). Much of the recent ‘case management’ has concerned this issue.

As a psychiatrist, my perspective on Seroxat is that despite much having been written about it, there may be more to productively explore about how it was introduced in the UK. My own recollection is that there was a good deal of ‘word of mouth’ negativity among psychiatrists, many of whom felt it was being aggressively marketed to GPs, in a way which covered up both the poor side effect profile (compared with other SSRIs) and the dubiousness of its licence for ‘Social Anxiety Disorder’. There was also some talk of discontinuation problems.

That was years before the first ‘Secrets of Seroxat’ programme. I never had a patient ask to try it, as happened with other antidepressants (especially Prozac in the mid-1990s).

My reading of this trial’s case management is that the claimants lawyers were seeking to explore some aspects of these wider issues of GSK’s behaviour, which are ‘on the record’ from other civil and criminal proceedings, and perhaps in non-legal settings. The case managing judge has determined that the focus should narrowly be on the UK marketing claims, and information submitted to UK regulators, but only in respect of discontinuation problems.

One interesting aspect of the trial is that Seroxat is apparently alleged to be ‘defective’, compared to other SSRIs, in the opinion not only of the anti-establishment David Healy, who has been associated with such a view for nearly two decades (see link above). The claimants’ other experts include prominent establishment psychiatrists.

Healy took over in 2016 from Malcolm Lader, who had requested withdrawing as an expert due to his age: Lader was first engaged on the case in 2005. He was then a professor at the Institute of Psychiatry (IoPPN) and is still an Emeritus.

Dr Matthew Hotopf FRCPsych is also an IoPPN professor, and is the director of the Maudsley Hospital’s National Institute for Health Research (NIHR) centre. The scope of his expert contribution has been narrowed from ‘epidemiology and statistics’ to just ‘epidemiology’.

‘Statistics’ has been taken over by Dr Glyn Lewis FRCPsych, professor at University College London, who has moved through the IoPPN as well as that other bastion of UK Pharma-psychiatry, Oxford.

So the idea that no establishment UK psychiatrist ever dares to undermine the interests of pharmaceutical companies appears incorrect, given the experts lined up against the UK’s largest.

Andrew Solomon’s The Noonday Demon: two decades of #MedHums marketing

(Note for readers new to my blog: although I argue for much greater Pharma-psychiatry regulation and scrutiny, I also oppose pillshaming and anti-diagnosis purism.)

This proposal (lightly edited here) has been accepted, and will be delivered as a twenty minute paper at the July 2019 biennial conference of Symbiosis: A Journal of Transatlantic Literary and Cultural Relations, in Dundee, Scotland. The deadline for proposals has been extended to 25th March.

 

Andrew Solomon’s The Noonday Demon (2001, new edition 2015): an example of US-UK BioPsychiatry marketing through #MedHums (Medical Humanities)

TND

In January 1998 the New Yorker published an autobiographical account of depression by one of its regular writers. Three years later the greatly expanded piece appeared in book form, and it would become arguably the single most impactful Anglo-American work, in any genre or discipline, to promote biopsychiatry in the last two decades.

The Noonday Demon received immense media attention and won over twenty book prizes. I have found only one review which dared to express any significant scepticism, by Joyce Carol Oates, who noted the hypnotic use of ‘mellifluous brand names: Celexa, Xanax, Viagra, Zyprexa, Effexor, Wellbutrin, BuSpar, Depakote, Klonopin, Halcion, Restoril, Zoloft, Paxil et al’.[1]

Andrew Solomon had just published his first (and only) novel, well reviewed in both the UK and the US, when he became depressed. He had a BA from Yale and an MA from Cambridge (England), both in English Literature, and he wove multiple literary quotations and biographical facts through his uplifting account of historical and contemporary neuroscience and psychopharmacology. The depressed and ultimately suicidal Virginia Woolf appears on the second page of the first chapter, and later the reader learns that Solomon was held in high regard as a Woolf scholar by culturally-informed New Yorkers.[2] Shakespeare, Sylvia Plath, and many other canonical writers are employed in the narrative which ends, in the 2015 edition, with an account of the author’s ongoing medications, monitored by both a psychiatrist and a ‘psychopharmacologist’, supplemented by visits to a third specialist, a psychotherapist.[3]

While there is no evidence that Solomon or anyone else ever employed deliberate deception, it is interesting that his father, a businessman, was the CEO of the company which came to license Celexa (under the brand name ‘Cipramil’ it was the UK’s bestselling antidepressant of the mid-2000s) in the US.[4] In 2010 the company, Forest Laboratories, pleaded guilty to criminal overmarketing to children, and was fined $313 million.[5]

I argue that mental health is especially vulnerable to a problematic notion of imbalance between The Two Cultures, potentially leading to an indiscriminate prescription of Humanities in order to counteract overactive Biomedical Science within the mental healthcare body.

As some Humanities scholars have pointed out, quite often ‘humanists can end up privileging medical understandings of health and wellbeing issues’.[6] While not disputing the truth of Andrew Solomon’s account, I explore how that may have occurred in The Noonday Demon and in its transatlantic reception.

 

[1] Joyce Carol Oates, Review of The Noonday Demon, The New York Times 24th June 2001: http://www.nytimes.com/books/01/06/24/reviews/010624.24oatest.html

[2] The Noonday Demon (Scribner, New York, 2015) pp. 87-8

[3] pp. 445-7

[4] https://www.bloomberg.com/news/articles/2002-05-26/a-ceo-and-his-son

[5] https://www.nytimes.com/2010/09/16/health/16drug.html

[6] Maria Vaccarella, Review of Paul Crawford et al., “Health Humanities”, BMJ Medical Humanities Blog (2015) http://blogs.bmj.com/medical-humanities/2015/05/05/the-reading-room-a-review-of-health-humanities/; Anne Whitehead,‎ Angela Woods (Editors) The Edinburgh Companion to the Critical Medical Humanities (Edinburgh University Press, 2016)

 

(Since submitting this abstract I have found a feisty review by Solomon, of James Davies’ Cracked, which defends biopsychiatry while acknowledging some downsides of Pharma’s behaviour. He accuses Davies of ‘pompous psychic Marxism’ and having a ‘smug view of human suffering’.)

Response to James Davies (CEPUK) on Pillshaming

(20th May 2019: I asked CEPUK to comment on their inconsistent position and they blocked me from Twitter. They also refused to comment on the wider range of approaches needed to remedy overmedication, or on my suspension initiated by an anonymous GMC psychiatrist. Recent Tweets suggest their primary concern is

Screenshot_2019-05-20 CEP on Twitter Anthropology teaches there are countless ways of validating suffering that don't invol[...]

to promote anti-diagnosis purism. Or perhaps their careers: James Davies is an academic anthropologist at Roehampton University.)

 

See: http://cepuk.org/2018/11/20/dr-james-davies-lets-clear-pill-shaming/

(Well done CEPUK for publishing this comment, in contrast to the closely linked MITUK , who have Peter Kinderman as their lead professional).

James Davies writes ‘I would agree that what is being called ‘pill shaming’ is both wrong and indeed does happen.’

Does he agree that pillshaming is encouraged by his fellow CEPUK ‘members of council‘ Dr Joanna Moncrieff, who has stated ‘there’s no such thing as an antidepressant’ (https://drnmblog.wordpress.com/2018/04/18/pillshaming-is-real-heres-a-newish-way-to-reduce-it-and-to-reduce-antidepressant-use/), and Peter Goetszche, who has disparagingly called them ‘happy pills’ (https://www.madinamerica.com/2014/01/psychiatry-gone-astray/)?

 

(Added 16th February 2019: I met James Davies at the 2018 ‘Critical Psychiatry Network’ conference and we had a good conversation about his book Cracked.

He has not responded to my above question. I have reminded CEPUK of it several times on Twitter.)

Maudsley ECT debate: two questions for each side

(See also my highly critical piece on John Read posted 10 days later)

‘Electroconvulsive Therapy (ECT) has no Place in Modern Medicine’

I have a ticket and will be voting against, because I know that many people have ECT on a voluntary basis, and it would cause them distress if it were withdrawn overnight.

However, I am quite sceptical about ECT: in ten years as a higher trainee and consultant in Learning Disability (LD) Psychiatry I only ever heard of one person with LD needing it in the UK. I went to national LD conferences regularly and often asked about ‘treatment resistant depression’, partly because as a student in 1984 part of my psychiatry placement was at the Brook Hospital, which was the last major centre for psychosurgery in the UK.

Two Questions for John Read (proposing to abolish ECT):

  1. You have compared ECT to ‘lobotomy and the rotating chair’:  https://twitter.com/ReadReadj/status/1033636959502008325  This seems close to the Scientologists who say that ECT is a deliberate form of torture, and point to early twentieth century history to support that view. As a psychologist, would it not be more honest to acknowledge that your profession has a dark history just as psychiatry does? Intelligence testing was central to eugenics (including deliberate killing in its most extreme form) in the early twentieth century, and more recently American psychologists have designed torture techniques for the US government:  https://twitter.com/peterkinderman/status/542425928773541889
  2. You have recently stated that you want a larger, better quality, randomised controlled trial (RCT) for ECT. You have also stated that you do not accept the concept of diagnosis, and propose an ‘alternative’, but as diagnosis (including a notion of severity) are necessary for an RCT of a treatment for severe depression how is this possible? https://twitter.com/NMacFa/status/1034063327847239680

Two Questions for Sameer Jauhar (against abolishing ECT):

  1. As a Maudsley Hospital consultant psychiatrist, and a researcher at the ‘world-leading’ Institute of Psychiatry, Psychology & Neuroscience, is not your professional and academic credibility undermined by an apparent culture of minimising ‘bullying, harassment and misogyny’ in those organisations?
  2. Given that the previous RCTs of ECT showed a significant placebo effect, do patients deserve more honesty about this to be able to give proper ‘informed consent? And is there a case for offering randomised sham or real ECT in clinical practice?

How ‘Drop the Disorder!’ colludes with the neoliberalism it claims to oppose

15-CPN-JM-SW-PK

(Panel discussion at the 2015 Critical Psychiatry Network (CPN) Conference: (left to right) Dr Joanna Moncrieff MRCPsych, CPN co-chair; Dr Simon Wessely FRCPsych, President of the Royal College of Psychiatrists (RCPsych) 2014-7; (unknown); clinical psychologist Peter Kinderman; Dr Hugh Middleton MRCPsych, CPN co-chair. Most CPN conferences have been reported, with accounts of the presentations, but although the Powerpoint slides were posted on the CPN website, I have been unable to find any report of this one.)

(Dr Wessely is discussed from the 9th paragraph, below)

 

Funding for mental health services has fallen in real terms over the last six years, and possibly over a longer period. As the editor of Asylum magazine, Helen Spandler, pointed out in her 2016 article, ‘From Psychiatric Abuse to Psychiatric Neglect?’, over the last 2-3 decades we have moved towards ‘the perverse situation where people may have to exaggerate their madness (and emphasise their dangerousness) in order to access or retain services. This is very worrying.’

‘Neoliberalism’ may not have one fixed meaning, but most would agree that cutting state-provided services in order to reduce taxes is a key element. Also, that Margaret Thatcher, more than any other politician, established it at the centre of political discourse from the early 1980s onwards:

 Image result for thatcherand sons

The Middle East journalist Patrick Cockburn is an expert in spotting unlikely political alliances, and he wrote this about Thatcher’s 1980s underfunding of ‘Care in the Community’: ‘The psychiatric hospitals were caught in a pincer movement from right and left. The left saw the asylums as being like prisons, whose inhabitants were primarily the victims of an authoritarian system. Films like One Flew Over the Cuckoo’s Nest propagated this attitude. On the right, such views were welcome because they provided respectable reasons for spending less money on the mentally ill and reduced the role of public welfare.’

In my view, calls over the last decade to ‘Drop the Disorder!’ represent a new form of this alliance between the ideological left, for whom treating and even supporting people with mental health problems distracts them from turning to socialism, and the state-shrinking neoliberal right. The beliefs that many such problems are either fictions promulgated by psychiatrists and the pharmaceutical industry (left version) or akin to malingering (right version, more straightforward now that profits on patent-expired psychiatric drugs are lower) are less in opposition than they might at first appear.

The CPN contains a range of leftist views, ranging from simplistic, even avowedly Marxist, ‘anti-neoliberalism‘, to lively cultural critiques, and more subtle approaches in which anti-capitalism is often buried in obscure discussions of Michel Foucault’s later writings on ‘Power’. CPN psychiatrists have mostly taken their anti-diagnosis discourse from ‘Critical Psychologists’, and I will only discuss Peter Kinderman as an example of the latter as he presented at the 2015 CPN conference; but he is probably the most prominent, having recently been president (and vice-president) of the British Psychological Society.

Peter Kinderman recently posted a talk he gave to a local Labour Party, full of lofty aspirations to ‘reduce financial and social inequality’ and promote ‘human rights’. He even had a photograph of Martin Luther King, who he quoted: ‘There are some things in our society, some things in our world, to which we should never be adjusted’. To be clear, I agree with these aspirations too, and with the view that inequality, abuse and trauma are major causes of mental disorder. But I differ in believing that support and psychotherapy will lead to more effective political engagement, not less.

Although he once, in passing, mentions mental health services as ‘under-resourced’, that is contradicted by the rest of the talk in which he implies great improvements can be made at no cost, or even with financial savings: he constantly stresses the claimed need to ‘reject…a diagnostic account of human distress’ but also reject ‘more of the same’ kind of mental health services.

No doubt these calls of ‘more money NOT needed here’ are pleasing to politicians in Whitehall, but also to Peter Kinderman’s local NHS managers in Liverpool.

But what of Dr Simon Wessely FRCPsych, who had become ‘Sir Simon‘ two years earlier, and at the time of the 2015 CPN conference was in his first year as President of the Royal College of Psychiatrists? Like their 1980s predecessors, The CPN and ‘Critical Psychologists’ tend to promote themselves as anti-establishment, so was the 2015 conference a confrontation, an occasion of mutual criticsm? Well, I have I have talked with several professionals and non-professionals who attended, and have been told that it was not. My explanation of this ‘mutual non-criticism’ follows.

Dr Wessely had been recruited to save money by ‘son of Thatcher’ Tony Blair’s government as early as 2001 (interestingly, Peter Kinderman reported a visit to the Department of Work and Pensions (DWP) in the same year). At the ‘Malingering and Illness Deception‘ conference in Woodstock, Oxfordshire, clinicians met both senior DWP staff and private companies whose ‘profits were threatened’ by disabling long-term disorders such as ME/CFS, which Dr Wessely (p.44) had based his research on over the previous decade.

Dr Joanna Moncrieff had been Dr Wessely’s MD student, and she had been interested in welfare as a drain on public spending even earlier, in 2000, when she published a paper warning that mental disorder-based ‘sickness benefits increasingly represent disguised unemployment‘. In 2016, a crack in the CPN’s ‘Drop the Disorder!’ consensus appeared when Dr Phil Thomas MRCPsych criticised another Moncrieff paper, which suggested that ‘to reduce benefit levels‘ was a valid primary aim for mental health services. Dr Moncrieff’s defence (below the Thomas critique, linked above), which started by irrelevantly stating that ‘almost all the data is already in the public domain’ and went on to repeat anti-neoliberal platitudes, was unconvincing.

Over the last 2-3 months I have come to the view that the CPN’s critique of the pharmaceutical industry is usually secondary to their concern about the ‘overmedicalisation’ of mental health:

Dr Moncrieff failed to respond to my point in this tweet. Since then, she has been silent about antidepressant hyping from the Maudsley Hospital/Institute of Psychiatry (where she did her MD), and about the overpromotion of ’emerging evidence’ claims from a leading psychiatrist employed half-time by GlaxoSmithKline (GSK) since 2005, who is active on a key RCPsych committee with Dr Wesseley. So has Peter Kinderman.

The selective criticism of pharmaceutical company behaviour by the CPN and ‘critical psychologists’ appears to go back, at least, to 2012, when there was little protest at the knighthood given to Andrew Witty, GSK’s CEO, for ‘services to the economy and the UK pharmaceutical industry’ (not for health), despite a $3 billion fine for overmarketing which was later confirmed as substantially ‘criminal’ and as partly relating to two antidepressants.

The CPN/’critical psychology’ alliance tends to claim sympathy with people who have difficulty withdrawing from antidepressants and benzodiazepines, but does not point out that medical supervision and support of such withdrawal is under financial pressure from their state-shrinking influence. Some ‘drug harmed’ people, who have been abused and shamed by another RCPsych ex-president, Dinesh Bhugra, as inventing or exaggerating ‘bizarre’ symptoms, partly motivated by ‘the incentive of litigation’, have noted a parallel between their experience and that of people with ME/CFS. Dr Moncrieff appears never to have commented on her former supervisor’s clinical area of interest, ME/CFS, but she has criticised patients’ self-advocacy as media-driven: ‘having a mental health problem has almost become a badge of honour among some sections of the popular press and numerous celebrity memoirs’ (p.77).

The unreported 2015 meeting between the CPN, Peter Kinderman, and Dr Simon Wessely shows that the post-Thatcher neoliberal state has found it useful to support a small but influential group of ‘Drop the Disorder!’ mental health professionals. In future Blog pieces I will explore aspects of this collusion further, and show how mental health diagnosis can be distorted and misused, sometimes oppressively, but is not inherently flawed as claimed by the CPN/’critical psychology’ alliance.

photo (4) - SW-JM-DS

Dr Simon Wessely after his presentation. Dr Moncrieff in the centre. Peter Kinderman (partly hidden) in the front row.

(My thanks to Dr Duncan Double MRCPsych (the only CPN psychiatrist who has criticised the RCPsych and Dr Ed Bullmore FRCPsych) for the photographs of the 2015 Critical Psychiatry Network Conference)

Added 20th January 2019: My earlier piece ‘Pillshaming is Real‘, is also relevant.

 

Twitter responses:

I am still waiting for Duncan Double (who seems to be a rare example of a politically centrist, or perhaps apolitical, diagnosis-sceptic) to back up his various responses:

DD links here to the 2014 Nutt & Bhugra Lancet article (I tweeted back that I didn’t agree I was ‘turning the tables’, and that I had deliberately avoided the ‘stigma’ issue):

In a later piece I will try and find some good evidence (although it seems obvious to me) that flat/reduced mental health funding leads to overmedication because that is cheaper than support and psychotherapy:

Added 5th June:

From the co-author of ‘The Dangerous Rise of Therapeutic Education‘ (2008), which argues that a wider ‘therapy culture’ is in itself harmful, and tends to distract from those who need specialist intervention. There is an update, including Mindfulness, in a 2015 Youtube video.

From @AkikoMHart (Mind in Camden, @HVN_England, @ISPSUK) who is currently looking at Dr Wessely’s MHA review. And also @RITB_

My response to @RITB_ was that ‘A Disorder for Everyone’ and ‘Power Threat Meaning Framework’ closely overlap in content and aims with ‘Drop the Disorder’.

Then a protest from the author of ‘The Psychological Complex‘ (1985) and ‘Governing the Soul‘ (1989), both of which influenced ‘Critical Psychiatry’:

From a Sheffield Humanities Professor who has written about the limitations of his own NHS psychotherapy. I would read (and agree with) his 2008 book chapter as arguing for less dominance of ‘scientistic’ CBT, and comment that Foucault and Heidegger (the latter un-named but present in the frequent use of ‘being/becoming’) are fine to explore in and out of therapy but in the wider context are useful for neoliberal state-shrinking.

CPN stalwart Duncan Double (see above) seems to be defending ‘Drop the Diagnosis!’ as being the only true path to Mental Health Utopia:

And finally, a response from the editor of Asylum Magazine, whose Twitter profile starts with ‘Politics of Mental Health’. Perhaps I misread her ‘From Psychiatric abuse to Psychiatric Neglect’ piece as calling for more Mental Health services funding?

‘The Inflamed Mind’ by Ed Bullmore: book review

Oliver James-tweet-‘The Inflamed Mind_-1

Dr Ed Bullmore FRCPsych is the most senior NHS psychiatrist in Cambridge (England), and says a ‘Cartesian divide’ or ‘orthodoxy’ is standing in the way of ‘the new science of immuno-psychiatry’. He invites us to believe that a third of all depressed people, over 100 million worldwide, could be identified with a simple blood test for ‘inflammatory markers’, and ‘be eligible for treatment with a new anti-inflammatory drug’.

The Inflamed Mind: A radical new approach to depression by [Bullmore, Edward]

If I sound sceptical, even cynical, it is with good reason. I have spent many hours listening to drug reps (pharmaceutical company representatives) and, to me, Dr Bullmore’s book could have been written by one. He appears to have worked, half-time, for one of the world’s largest Pharma companies, GlaxoSmithKline, since 2005, and it is no surprise that his rhetoric against ‘professionally conservative’ medicine seeks to create a need for a ‘new’ drug.

What is wrong with the ‘old’ drugs? He writes:

‘An obvious idea would be to try taking one of the many anti-inflammatory drugs that are already in widespread use, like aspirin…there is no solid evidence that aspirin or any other anti-inflammatory drug already in medical use has anti-depressant effects. The clinical trials…have simply not been done.’

‘Aspirin, for example, commonly causes stomach irritation, ulceration and bleeding…a careful doctor in 2018 is likely’ not to use ‘existing anti-inflammatory drugs’ for depression.

This is misleading in at least four ways. Firstly, ‘aspirin’ is named three times (and once more, elsewhere), rhetorically foregrounding it as typical, but it is not. For most ‘careful doctors’, an NSAID with less marked side effects would be the first choice for ‘inflammation’. I myself took ibuprofen 3-4 times a day for several months, with no significant side effects, when I had a frozen shoulder. A new NSAID with no gastrointesinal side effects would make a lot of money, so perhaps Dr Bullmore is letting us know that his employer does not have one in the pipeline.

Secondly, ‘the clinical trials…have simply not been done’ suggests ‘conservative’, perhaps ‘Cartesian’, medics selfishly want to block ‘transgressive’ and dynamic ‘immuno-psychiatrists’ from helping the 100+ million. The real reason is that ibuprofen and other NSAIDs are out of patent, so non-Pharma funding for the trials would be needed.

Thirdly, it is true that ‘a careful doctor in 2018 is likely’ not to use ‘existing anti-inflammatory drugs’ for depression, but that is because of the lack of clinical trials and, in the UK, NICE guidance, not the side-effects of generic NSAIDS.

Fourthly, the need for new anti-inflammatories for depression seems less urgent if there is only ‘some evidence that inflamed patients respond less well to anti-depressant treatment with conventional drugs, like SSRIs’. Earlier, there is a more upbeat ‘increasingly clear’ statement on this, but the only citation provided is from 2006, so perhaps the increase of clarity has levelled out in the dozen years since. There is also no mention of evidence that people with ‘inflamed’ depression either respond less to psychotherapy or have less tendency to spontaneously improve.

For all I know, the research base outlined for cytokines and other components of the immune response having a mediating, or even sometimes a more directly causal, role in depression may be quite sound. However, Dr Bullmore’s wide-ranging 2009 defence of neurosciency hype in psychiatry means that his account cannot be taken on trust. In this book he repeatedly claims that his ‘post-Cartesian’ approach reduces the ‘stigma’ of depression and other mental health problems: but in 2009 he himself attempted to smear critics using a stigmatising mental health label, as ‘neurophobic‘.

Even more self-undermining is Dr Bullmore’s highly selective account of GSK and neuroscience. How can he write about his meeting with the ‘Senior Vice President of Research and Development’ in 2012, but not mention the $3 billion ‘criminal’ and ‘civil’ convictions in the United States, for bribery and fraud which included two antidepressants (Paxil/paroxetine and Wellbutrin/bupropion), in the same year? And worryingly for the reputation of more lowly researchers in the wider field of biological psychiatry, Dr Charles Nemeroff MD, who was sacked by one University in 2008 for lying about large payments from GSK, appears to have serenely carried on as a leading researcher in the field, at another.

Dr Bullmore writes that in 2010 GSK suddenly announced it was ‘strategically exiting the whole area of mental health’, and here the account becomes rather opaque. He implies that the supply of new antidepressants dried up across the whole industry: ‘Acting rationally, companies have stepped back, not wanting to put good money after bad’. Unsurprisingly, he makes no reference to the UK’s MHRA criminal investigation into the notorious Study 329, or to CEO Andrew Witty’s knighthood in early 2012 for ‘Services to the Economy’, rather than to Health.

For me, though, the key flaw of this book is the near-absences of the placebo effect in the treatment of mild and moderate depression, whether ‘inflamed’ or not, and the tendency for most episodes to get better anyway, with adequate support. Despite a rare moment of good sense in which Dr Bullmore writes ‘Stress is one of the most well-known, and one of the least understood, causes of depression….a massive effect, especially for…major life events’, I fear that his aim is to prepare the way for new patented drugs to get through the lax regulatory frameworks which exist in both Europe and the United States.

(Added 8th May:

Pillshaming is real: here’s a new(ish) way to reduce it, and to reduce antidepressant use

(Note added 16th February 2019: see my latest piece on ‘Critical Psychiatry‘)

Some ‘Critical Psychatrists’ have gone too far in stating that ‘There’s no such thing as an ‘antidepressant’’.[1] Although the evidence shows that, even in moderate depression, nine out of ten people (maybe many more) will be getting largely a placebo effect, it is less clear whether the additional distress caused to antidepressant users by such talk is outweighed by the benefit to those who are warned off, and stay medication-free.

And anyway, UK antidepressant use has doubled in the decade since the publication of psychiatrist Dr Joanna Moncrieff’s Myth of the Chemical Cure (2008), and Harvard psychologist Irving Kirsch’s The Emperor’s New Drugs (2009). In that time, the patents on almost all UK antidepressants have expired: so while there are still profits in brands and generics, pharmaceutical marketing has reduced a lot.

It may be difficult to prove that this hectoringly negative approach has been counterproductive, and actually increased prescribing; but social science research published in 2015 shows that ‘pillshaming’ is real, and often more than a mild irritant. The University of Westminster’s Professor Damien Ridge has been studying this issue for a decade, and with his co-researchers he found that many users were ‘concerned about shameful antidepressant use and deviance’, some even struggling with the idea that they were ‘malingerers’.

It will be of concern, to people who have experienced pharmaceutical harm, that it does not feature more prominently. I myself wonder if Dr David Healy, who still maintains that antidepressants cause more harm than good, if not adequately monitored,[2] is not a little too focused these days on his expert witness work, rather than engaging with regulatory authorities and the wider public.

The first four words in the title of Professor Ridge’s 2015 paper, a quote from a person on antidepressants, is telling: ‘My dirty little habit’.[3] (academic paywall, but I will later do a longer Blog piece on Ridge’s work)

So, is there an alternative to ‘pillshaming’, that will still draw attention to the very limited direct pharmaceutical effect for at least nine people out of ten? Arguably, doctors should be telling patients about the latter anyway, and imminent new guidance from the GMC on ‘a doctor’s duty to disclose relevant information and risks’ may be an opportunity for ‘antidepressant’-skeptics like myself to foreground concerns again.[4]

I suggest that new patients (with non-severe depression) about to be offered antidepressants are offered a placebo as well. Note: ‘as well’ rather than ‘instead’, because for the patient not to be informed is unethical, and although there is some interesting research on people knowing they are taking ‘sugar pills’…well, let’s not go there.

I am talking about a parallel with randomised controlled trials, but as a routine structure of treatment, not as research. At its simplest, there would be a fifty-fifty chance of getting the placebo, and the treatment would be ‘unblinded’ after 8 weeks. A greater level of complexity would involve a longer period of, say, 12 or 16 weeks, with a crossover in the middle.

Who would provide these ‘blinded treatment trials’ first? Psychiatrists have more time for patients, but they tend to see either more complex cases or more severe depression. It might be best for those GPs, especially academics, who have a serious interest in mental health, to take this up. They would be well-placed to run pilot schemes identifying people presenting to GPs with more straightforward moderate depression.

Of course, many people would turn down the treatment trial, and opt for ‘unblinded’ antidepressants. But at least they would have been informed about placebo, and even potential harms, in a less shame-inducing way.

(Added 21st April: thanks to Dr Duncan Double MRCPsych for comments on a very early version of this piece)

(April 22nd: Paragraph 4, ‘it does not feature more prominently’ changed from ‘little awareness of it was reported’)

(Added September 19th: search my other Blog pieces for ‘Anti-Diagnosis’)

 

[1] https://joannamoncrieff.com/2013/11/27/why-theres-no-such-thing-as-an-antidepressant/

[2] http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/suicide-prevention/written/37289.html

[3] https://www.sciencedirect.com/science/article/pii/S0277953615301568

[4] https://www.bmj.com/content/357/bmj.j2224

%d bloggers like this: