Request, and Questions, to Oxford researchers Dr Andrea Cipriani ARCPsych and Dr John Geddes FRCPsych
(Sent by email 18.00 today)
Dear Dr Cipriani and Dr Geddes
I intended to email you with some questions about your 21st February ‘network meta-analysis’ paper, but as you have published personal (ad hominem) abuse in your 5th April Lancet Psychiatry Comment I will start with my request.
You wrote: ‘some coverage in the media and social platforms was inaccurate—in particular, there was an undue focus on the binary and polarising question of clinical significance. People can always manipulate information to fuel controversy and this appears to occur frequently in the stigmatised area of mental health.’
This clearly implies that many practitioners, and many others concerned about harms from antidepressants, were primarily motivated to mischievously ‘fuel controversy’. You do not cite any evidence for this claim, and without wholly adequate evidence it is therefore ad hominem (to the person) abuse. Please provide such evidence, or withdraw the claim and apologise, with adequate publicity.
As someone who believes he is among the targets of this personal abuse, I reject the implication that my valid criticisms fuel stigma: the opposite is true, in my view. I am not merely a psychiatrist but someone who has been a patient, in the NHS, with depression.
1. Dr Carmine Pariante commented on the 21st February paper as the Royal College of Psychiatrists spokesperson, not as an academic. I have complained about his statement and that has now been escalated to the GMC. When did you provide the 21/2 paper to him (or the College)?
2. Did you provide previous versions? If so, when?
3. Did you communicate with Dr Pariante about the paper, or provide any additional information about it, before or on the day of publication? Please give an account.
4. Your use of ‘antidepressants might work’ in the title of your 5th April comment appears to be a striking retreat from your statement to the BBC: ‘This study is the final answer to a long-standing controversy about whether anti-depressants work for depression. We found the most commonly prescribed anti-depressants work for moderate to severe depression…’
Do you accept that it was you yourselves who made the ‘question of clinical significance’ into a ‘binary’ one?
I fail to see how the answer to the last question can be anything other than ‘yes’, but will consider any evidence or reasoning you provide. Please note that as ‘the final answer’ did not appear in the Lancet, I consider it legitimate to ask you outside of its correspondence function.
I submit the questions to you as practitioners, not academics: academic freedom is not relevant. If I do not receive a full and adequate response, to the request and the questions, in seven days (18.00 Monday 16th) it is likely that I will submit complaints to the NHS Trusts where you do your clinical work and research.
On the issue of communication with Dr Pariante, you are respectively an associate and fellow of the College and I will consider a parallel complaint there.
Dr Neil MacFarlane
Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.
As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.
I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.
On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.
His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.
He might be right, but I think at least two aspects of the debate have not received as much attention as they should.
First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of “only” a few hundred people developing schizophrenia?
Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.
When UK general practitioners, from the mid-1990’s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.
Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.
Manufacturing Depression: the Secret History of a Modern Disease had been in my “to read” pile for a few months. I was in no hurry, assuming from the title that it was a re-hash of the “marketing by pharmaceutical vested interests” arguments of David Healy and others.
But after a patient recommended it, I had a look. The author Gary Greenberg is a psychotherapist, who has episodes of severe depression himself, possibly related to his “inexhaustible penchant for dithering”. He tells a very interesting story, especially about taking part in a double-blind, placebo-controlled trial of an antidepressant. I will not reveal the ending, but do think the book should come with a bit of a health warning because the lack of black-and-white conclusions may make some readers irritated or even depressed.
Another thing I liked about Manufacturing Depression was Greenberg’s willingness to say that pharmaceutical companies and medication prescribers are not the only vested interests in the mental health “industry”. For example: “…even though I am a psychotherapist, I don’t think the only alternative is what I sell in my office one hour at a time”. And, as what Greenberg calls a “depression doctor” myself, I agree with his view that “Depression is surely an affliction, one that at least in some cases may well have a specific, although still undiscovered, brain pathology – a disease in the usual sense of that word.”.
Quotations from Manufacturing Depression: the Secret History of a Modern Disease (2010, Bloomsbury hardback): pages 365-6, 297-8, 13
This was the title of a talk by the philosopher and journalist Robert Rowland Smith, at London’s School of Life two days ago.
I have known Robert for a couple of years, during which he has published two books exploring how philosophy is relevant to the everyday dilemmas of modern life: Breakfast with Socrates and Driving with Plato.
The essence of the talk, I think, was that despite regular reminders throughout history of humanity’s less than fully rational nature, we still tend to overestimate our self-control. The constant development of technology not only distracts us from evidence to the contrary, but creates neurotic
dissatisfaction which we tend to worsen by seeking relief in materialism rather than by improving our interpersonal relationships.
I’m not sure that Robert is right in seeing the Western rational “Enlightenment” as perhaps now needing some sort of counter in the form of an Endarkenment”, because I think that contemporary philosophies and psychotherapies, as well as older Romantic Western culture, offer a whole range of ways to explore what Jung called our “shadow aspects”. And some people who are stuck in over-rational ways of life are suffering from biologically-based problems such as depression (1) or autistic spectrum disorders: they may need medication or other treatments to fully take part in philosophical or psychotherapeutic discourse.
It might seem odd that medical technology is sometimes necessary to enable a less technologically-dependent life. But in my view this is just a particular case of science liberating rather than oppressing (2). Philosophy too contains many paradoxes of this kind, such as Wittgenstein’s recommendation that we should simply stop chattering about “things of which nothing can be said”: his non-silence was required first, so that therapeutic silence could follow.
(1) In general the more severe and long-lasting the depression the greater is the need for medication. But some severe depressions may respond well to psychotherapy and/or philosophy, and some mild depressions may respond only to medication.
(2) Of course, technology and science are often used oppressively, or at least with neglect, whether deliberately or by mistake. Antidepressants prescribed after a ten-minute consultation with a GP (rather than a much longer consultation with a GP, psychiatrist or clinical psychologist), including little or no discussion of psychotherapy, amounts to state-sanctioned neglect in my view.