However I did find time to gently ‘troll’ its lead author about her links to the pharmaceutical industry, and my piece published today attempts to say why I think that might be relevant for the ‘Recovery Narrative’ and ‘genre’ paper, and the so-called ‘Medical Humanities’ more widely.
Regular readers of my blog will know that in January I suggested a co-author of the ‘Narrative’ paper, Professor Helen Spandler, was running Asylum Magazine as ‘a self-censoring academic front for establishment psychiatry’.
As a psychiatrist long interested in English Literature, who spent much of 2013-17 drafting proposals for a self-funded MD or PhD, I had come across Angela Woods’ work before. She co-edited a 700-page 2016 book on the ‘Critical Medical Humanities’ but, alas, as with so-called ‘Critical Psychiatry’, the claim to be broadly ‘critical’ is questionable.
If one probes for key words on Google Books (and I have also searched the whole text in the British Library), one gets the impression that ‘Western biomedicine’ (for example) is something undesirable ‘practised historically by white males’ etcetera. But the nature of its undesirability, and how it maintains its ‘hegemony’, is circled around rather than stated.
There is no mention of Ivan Illich’s Medical Nemesis, let alone more recent critics such as Marcia Angell, or David Healy. Yes, Nikolas Rose is referenced, but in my view he is more of an observer and chronicler of biomedicine than a critic of its downsides and excesses.
So Pharma-dominated medicine (including Pharma-psychiatry) has little to fear from this kind of academic ‘output’. And that may be partly a consequence of how most ‘Medical Humanities’ in the UK is funded.
Some more fact-checking is required, but most humanities academics I have talked to over the last 6-7 years have believed it to be overwhelmingly backed by the Wellcome Trust, a 26 billion pound charity which mostly invests on the stock market (excluding tobacco, which might put the #Pharma proportion of the portfolio up a bit from the usual 10% or so of the FT 100 benchmark) but also develops its own vaccines and other pharmaceutical products. (Full disclosure: at one point I explored whether funding for my own MD or PhD might be available from the Trust).
Professor Woods appears to be still part of a major Wellcome project and, interestingly, one of her colleagues at Durham University is a Wellcome-funded anthropologist, with an interest in ‘narrative’, who researches ‘health conspiracy theories. These include beliefs about secret agendas behind vaccination programs, the side effects of medical treatments, and cover-ups by the government or pharmaceutical industry.’
On his University page, professor Tehrani simply makes a much vaguer reference to research on ‘conspiracy theories’ (dropping ‘health’), and does not mention his Wellcome funding. However, scrolling down does show his most recent paper was on ‘antivax attitudes’.
Coming back to the paper on ‘Recovery Narrative’ as a ‘genre’ (the first link in this piece), how might Wellcome’s ‘#Pharma-loaded’-ness be relevant?
Well, the role of the pharmaceutical industry, in promoting biomedicine while marginalising psychosocial understandings and interventions, is completely absent.
Take the semi-fictional ‘Ben…a young person struggling with unusual experiences’ in the second paragraph: ‘When he becomes part of a dynamic mental health charity, his world transforms. He grows in confidence and…he becomes an ambassador for a major national anti-stigma campaign…’.
There is no mention of the degree of funding of the charity by Pharma. Some charities disclose the names of companies, but there is no obligation to do so, and I am not aware of any that itemise exact figures. There is also the issue of industry disclosure, by professionals with formal or informal charity roles, being only voluntary (see No. 4 of my ‘manifesto’).
Ben’s ‘narrative’, as told by the two Wellcome-funded professors and their co-author, continues with his audience getting bored with him, and eventually ‘From hospital, where he has been sectioned, he speaks of a painful ebbing away of his sense of self-worth.’
The suggestion, as I read it, is that ‘Ben’ is more a victim of the media’s general tendency to build up ‘fresh faces’ and later knock them down, rather than of Pharma-psychiatry which has a vested interest in mental health services being poorly funded, so that drugs are used rather than more expensive person-delivered support and psychotherapy.
In the 10,000 words of the whole paper the word ‘drug’ does not appear, and even ‘medication’ only does so twice, with the mildest (if any) of ‘critical’ inflection: ‘The Recovery Narrative can…suggest multiple pathways to recovery (including therapy, medication, familial or peer support, religious counselling, and mental health activism)…’.
I suggest a ‘genre’ for this paper, sadly not a new one: ‘Academic Output Disguising Industry Interests’.
‘Mothers on the Edge’ was broadcast last night.
Thanks to the anonymous* source in the South London and Maudsley Hospital Trust PR department for reporting the following conversation, which took place about eighteen months ago:
‘Great! Louis Theroux is interested in filming on the perinatal unit.’
‘Is that really a good idea? His 2010 programme on ‘America’s Medicated Kids’ received quite sceptical reviews about psychiatry and medication from the Guardian, and Mumsnet readers. Louis got the children and teenagers to open up quite a lot, undermining the idea that their behaviours were merely ‘symptoms’. He even filmed a Pittsburgh psychiatrist admitting that drugs were often used in preference to psychosocial interventions.’
‘So he won’t stray from the script of psychiatrists doing their best to be psychosocial, and only using medication if absolutely necessary?
‘We have already agreed the consultant will not be challenged on claims about ‘trauma’ being addressed in all patients. No awkward questions about #Pharma COI involving SLAM, or personality disorder, either.
‘I am still surprised they want to film at one of the best-funded perinatal units in the country, rather than somewhere that is struggling and likely to use even more drugs.’
‘The BBC are much less interested in challenging the medical establishment than they used to be. Of course we want to be discreet about ex-BBC journalists now working in PR, but unfortunately some, like the RCPsych’s Kim Catcheside, can’t resist bragging occasionally about their influence.’
* and fictional.
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:
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.
(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
to promote anti-diagnosis purism. Or perhaps their careers: James Davies is an academic anthropologist at Roehampton University.)
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.)
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’.
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:
(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’’. 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, 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’. (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.
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’)
RCPsych oligarchy now appears to be deliberately misleading while spinning its response to my complaint about its statements on Cipriani et al
DO NOT STOP ‘ANTIDEPRESSANTS’ BEFORE DISCUSSING WITH THE PRESCRIBER
RAISE THIS ISSUE WITH YOUR GP (OR PSYCHIATRIST) AND ASK ABOUT ALTERNATIVES
PLEASE NOTE that when I write ‘antidepressants’ I respect those who have experienced a non-placebo therapeutic effect. In any individual person, this is impossible for a psychiatrist or other health professional to rule out clinically. However, the group-based research evidence shows fewer than 1 in 10 have a substantial non-placebo effect and the true figure may be much lower. Depression has a natural tendency to improve and ‘antidepressants’ may worsen the medium- and long-term outcome for most people: the research on that is inadequate, in my view, but some psychiatrists and many people who have experienced harms from ‘antidepressants’ are more certain.
[Complaint: 15th March…20th April: RCPsych promised response by 11th May…15th May: no response]
I complained to the RCPsych (Royal College of Psychiatrists) on 15th March, about the ‘false, misleading and irresponsible’ statements made about this ‘antidepressant’ meta-analysis in the Lancet (21st February), by its spokesperson Professor Carmine Pariante. I am a member, but anyone can complain about its public statements and activities. They have not responded (other than to acknowledge), and misleadingly cited the College’s regulations when they ordered me to keep silent about their responses.
Here is my complaint, with some questions at the end. I say that Dr Pariante’s ‘finally puts to bed the controversy on antidepressants’ is irresponsible and misleading; that he repeated the Lancet paper’s false claim about lack of selective reporting of antidepressant trials by pharmaceutical companies; he trivialized criminal wrongdoing by pharmaceutical companies and he has a history of so doing. He evaded the issue of trial registration, and he endorsed overmedication contrary to College policy. Dr Pariante falsely stated that the Lancet paper addressed antidepressant ‘safety’, and in not mentioning placebo response his statement was misleadingly biased towards drug treatment.
There is a technical-seeming bit in the first section, on funnel plots, but actually the point is what the Cochrane Review (an international body which conducts statistically-informed evidence-based studies in Medicine) now say about funnel plots, which appear to be largely discredited as a way to detect publication bias.
Link to 180315-3_Pariante_complaint (pdf, main complaint is 3 pages, plus Dr Pariante’s full statement at the top, and some questions at the end. Total, 5 pages)
The College oligarchy decided to spin part of my complaint in the Mail on Sunday (link within link to Tweet, below) rather than respond in a formal way. This insults people with mental health problems, and degrades public discourse on the issue. Profesor Pariante was briefly quoted as saying he was ‘taken very much out of context’. I believe most people will find this deliberately misleading. He also mentioned ‘placebo’ for the first time. Much of the substance of my complaint has not been addressed, including his false claim that Cipriani et al addressed the ‘safety’ of ‘antidepressants’.
Yesterday, the oligarchy tweeted that he had ‘readdressed comments’. They need to clarify if he had already ‘addressed’ them (which I am unaware of) or if this is, again, misleading:
Why the RCPsych ‘oligarchy’, and not the President, Professor Wendy Burn? Well, she is not particularly known as an overpromoter of medication, but it is possible that in her role as Dean from 2011-6 she kept such views quiet. Recently, she and Professor David Baldwin made a very dubious claim about coming off medium and long-term prescriptions of ‘antidepressants’ (not an issue addressed by Cipriani et al) which, together with Professor Baldwin’s empty and inept response, is now the subject of another complaint, which I will inform the College today that I support. Professor Baldwin is the RCPsych’s senior officer for medication (‘psychopharmacology’).
But the key RCPsych oligarch may simply be Professor Pariante himself. The day after his 21st February statement he tweeted the RCPsych’s ‘Senior Communications Officer’, and her response suggests that the President could have given him free rein:
I think someone from outside the inner circle should come in and take control of this issue. The best I can think of right now is Professor Louis Appleby, who is prepared to state the obvious about corporate pharmaceutical behaviour, although how strongly is not clear. He also corrects and clarifies his statements with honesty:
[First 11 lines added 29th March 10.00]
[3rd paragraph added 3rd April]
[‘1 in 10’ changed from ‘1 in 5’, 3rd April]
[Complaint: 15th March…20th April: RCPsych promised response by 11th May…15th May: no response]