Transparency: Revision of NICE guidance on Depression

In a recent post I shared a letter that I had sent to the BMJ that was not published. It was based on correspondence with Professor Sir Simon Wessely who is one of the members of a stakeholder group who requested a revision of the Draft NICE Guidelines on Depression in Adults: Recognition and Management

In correspondence with Professor Sir Simon Wessely he suggested that I make a Freedom of Information request to NICE. I have followed this advice and have now received the following four documents (shared here below as received).

I also share here, to provide full, open, and transparent context, the correspondence that I had with Professor Sir Simon Wessely. I will let the reader decide on whether this is the correct thing for me to do or not. I have concerns that such a powerful and influential UK medical leader should confuse transparency about a matter of public interest with me as a person and then challenge my probity.





Correspondence with Professor Sir Simon Wessely on NICE Guidelines on Depression in Adults: Recognition and Management

From: Gordon, Peter J [mailto:Peter.J.Gordon@nhslothian.scot.nhs.uk]
Sent: 08 June 2018
To: Simon Wessely and to NICE
Re: NICE Guidelines on Depression in Adults: Recognition and Management

8th June 2018.

Dear Simon,
I find the lack of transparency concerning. I note that this was one of the very concerns that your expert group challenged NICE on. Surely this is kettle-pot-black.

Perhaps you might be able to help provide all written communications to NICE from all members of this expert group?

Kindest wishes,

Dr Peter J Gordon
GMC number 3468861

Consultant Psychiatrist for Older Adults
NHS West Lothian


From: Wessely, Simon
Sent: 08 June 2018
To: Gordon, Peter J
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

Peter You have got me this time I have no idea what you are talking about Am not on and have never been on any NICE Guideline Committee

Simon


On 8 Jun 2018, at 12:36, Gordon, Peter J wrote:

Sorry Simon, but I had understood you were part of the “expert group” who brought about a second consultation on the NICE Guidelines on treatment of depression, and that the group you are part of,  met with NICE on 27 April 2018

It is recorded details of this meeting and communications from the group you are part of to NICE that should be in the public domain.

I look forward to your response.

aye Peter


From: Wessely, Simon
Sent: 08 June 2018
To: Gordon, Peter J
Re: NICE Guidelines on Depression in Adults: Recognition and Management

A ah That letter Yes I signed a letter which is in the public domain because it was published in a newspaper
B I have never attended a meeting of any group I don’t have the time
C I don’t am afraid agree that if there was a group and if there was a meeting and if there were any minutes from that , that you have any right to see any of those, any more than you would have any rights to hear a transcript of a conversation I had yesterday with a bloke in the pub about some recent nice guideline and what we shoukd do about it. On the other hand any communications to nice are indeed FOI able as you know

Let’s not prolong this correspondence peter

Simon


From: Gordon, Peter J
Sent: 08 June 2018
To: ‘Wessely, Simon’
Subject: RE: Depression in adults: treatment and management

Indeed, let’s not prolong this correspondence. I did not know that about FOI and NICE.

My view is all material relating to any Guidelines being developed should be open as these Guidelines may result in interventions that may bring about a range of outcomes, between benefit or harm.

I worry about your memory Simon.

I will add your responses (below) to my blog

Kindest wishes
aye Peter

Dr Peter J Gordon
GMC number 3468861


From: Wessely, Simon
Sent: 08 June 2018
To: Gordon, Peter J
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

No peter don’t add to your blog This is private chit chat You have not asked my permission and I don’t grant it


From: Gordon, Peter J
Sent: 08 June 2018 13:30
To: ‘Wessely, Simon’
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

This was not private communication. If you are worried about what you say about NICE Guidelines said in PROFESSIONAL correspondence about a PUBLIC matter then perhaps you need to reconsider what you write.

aye Peter

Dr Peter J Gordon
GMC number 3468861


From: Wessely, Simon
Sent: 08 June 2018
To: Gordon, Peter J
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

No peter it isn’t This is a private e mail interchange If you had said “this is for my blog ‘ fair enough But you didn’t. Do you really not understand the difference? I frankly don’t care to be honest and nor will anyone else but I think it’s very shabby indeed to reproduce a private correspondence in this way, at the very least it’s extremely discourteous and you and I have always corresponded perfectly amicably in the past with genuine courtesy and mutual respect

That’s what it is about If you had actually asked me if I minded you putting this in your blog I would probably have agreed but you didn’t and simply announced it as a diktat and so now I don’t

If I cannot trust you not to publish private e mails then I am afraid I shall not enter into any further correspondence with you again and I am perfectly happy fir you to put this into your blog It’s a matter of courtesy peter it’s probably also these days covered by some Data protection regulation or other but that’s not my beef It’s that you shouldn’t assume you can publish a private conversation without asking first

Sink


Peter’s blog post “Sink”:


From: Wessely, Simon
Sent: 08 June 2018
To: Gordon, Peter J
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

Peter
The letter that went to NICE that I signed was also published in a national newspaper, so no surprises there, but as with any correspondence with NICE, it would be FOIable. So any attempt to influence, subvert, or whatever words you wish to chose , NICE are indeed already available to you If you chose to ask them. Am surprised you didn’t know that.

I would submit that how that letter was put together is indeed none of your business. Although to be honest given that the topic is a concern expressed by many people many times that the NICE guideline process has become too rigid so that in this instance it risks damaging a whole range of talking therapies, such as family therapy, marital therapy, psycho analytic approaches and so on from being provided on the NHS, this is hardly a smoking gun reeking with the smell of Big Pharma. But as I say, how it came about does not need to be transparent and there is no public or legal right to make it transparent, as I am sure you know. Whether the people involved met, spoke on the phone, communicated by the power of thought or the medium of dance, is none of your business. What is transparent is what was sent to NICE. Which you already know. And as I say, there is no story here anyway – we were merely expressing what people like me have been expressing for a long time – that i am worried that the provision of talking therapies is becoming too monolithic. I said so when I took office and I still say so today.

So I repeat. This is a daft thing to fall out about. But so be it if it comes to that, but you need to be clear that my irritation is your assumption that you had the right to put into your blog what I and I think anyone else would classify as a private e mail, written by you as a private citizen to me as a private citizen. It would be the same if one of my sons wrote to me and said “Dad, what was going on with that letter you had in the Guardian yesterday?” . That is clearly a private matter unless of course both parties, and I stress the word “Both”, decided to make it public. Imagine my son’s reaction if I went and put his e mail to me into a piece without asking him first?

So if you were perhaps to change tack a little, realise that actually being polite and courteous is not such a bad thing, even if a little old fashioned but there is nothing wrong in that, and not write your blog with this interchange in it, until you have asked if I mind, then you might get a different response.

But you wont get it for a while now because believe it or not I am off to do my afternoon clinic

Simon


From: Gordon, Peter J
Sent: 12 June 2018
To: ‘Wessely, Simon’
Subject: Re: NICE Guidelines on Depression in Adults: Recognition and Management

Tuesday, 12th June 2017,
St John’s Hospital,
Livingston.

NHS Lothian.

Dear Simon,
You use the word “subvert”. That is not a word that I would ever use. The words I used were transparency and openness. As for the “smoking gun” or “shooting foxes” (how you began one of your previous communications to me) I dislike military metaphors and I really have no wish for “combat”. We are all simply trying to bring about health and wellbeing. I wrote to you seeking transparency of a process and you, in your very powerful position, turned this away from the subject and into communications that robustly and repeatedly questioned my probity.

The language you use Simon is both interesting and revealing: “reeking of the smell of Big Pharma”. Why say this? My writings demonstrate that I am interested in ethics of healthcare and the potential for any interventions (social, psychological, pharmacological, whatever) to bring about benefits or harms. You seem to wish to understand me from a position of misplaced medical antisyzygy. My concern is that you do this deliberately. It is a feature of many of your responses.

I note your view (noting also that you are President of the Royal Society of Medicine): “ how it came about does not need to be transparent and there is no public or legal right to make it transparent, as I am sure you know.” And then you say “there is no story here”. These statements seem contradictory and reveal that your view of transparency should be all that matters.

I agree that this is a “daft thing to fall out about”. But I have not fallen out with you. I was simply disappointed that you were not able to be open and transparent about the process of my enquiry about NICE. I understand your irritation, but this is not about you Simon, at least that was not why I wrote to you as an NHS doctor about a matter that may affect any patient.

You say “I think anyone else would classify as a private e mail, written by you as a private citizen to me as a private citizen.” No. I repeat this was a professional e-mail from my professional address to your professional address about a PUBLIC matter. I believe that you are wrong in “thinking” that “anyone else would classify it as a private e-mail”.

I have seen you use the following line, or similar, a number of times to a number of correspondents:

“So if you were perhaps to change tack a little, realise that actually being polite and courteous is not such a bad thing, even if a little old fashioned but there is nothing wrong in that”.

It seems that other correspondents have also been worried about this statement which carries your assertion that this applies to others and not to you. This is why others, like me, have chosen to let others see the way you personalise discourse on matters of public health.

Simon, I am concerned about your outlook, your use of language and your memory. I am sorry that you struggled to get most of the letters of your Christian name correct. Forgive me for misunderstanding that “Sink” was not your name.

I wish you all the best but I do not wish to receive any further communications from you.

Kind wishes,

Dr Peter J Gordon
GMC number 3468861

Consultant Psychiatrist for Older Adults
NHS West Lothian


21 Replies to “Transparency: Revision of NICE guidance on Depression”

  1. As a professional replying to another professional on a professional matter, Wessely’s attitude leaves a lot to be desired (understatement). In fact, even if it was a private email, the same standard applies! As a psychiatrist who supposedly understands people, his manner is unbelievably condescending and dismissive, as if he is in fact speaking to his teenage son.

    1. Dear Alison,
      No minutes were taken and the meeting was unrecorded. I find this disappointing and concerning.

      aye Peter

      1. I agree, very concerning indeed. NICE decision-making should be transparent. I wonder if the non-recording was deliberate.

  2. Thanks for sharing publicly what many have experienced privately: That power and arrogance are an ugly and suppressive mix.

    1. Thank you for this comment, I share your concerns about how power may be used and misused.

      Obama recommended to students that they should “engage in debate with those who share different beliefs” and that they should “feel free to disagree with somebody but don’t just try to shut them up”. Professor Sir Simon Wessely does not seem to share this philosophy.

      aye Peter

  3. Dear Peter,
    Thank you for making this public. It was the correct thing to do because it helps others such as myself understand what is really going on in psychiatry.

    I am a physician rather than a psychiatrist, but have become interested in ME/chronic fatigue syndrome. I have also received emails from Simon Wessely trying to persuade me of his position through distracting bonhomie while asking for confidentiality. There is of course a lot of circumstantial evidence for interference by Mr and Mrs Wessely and friends in policy making. Only last week a senior figure in an organisation tasked with assessing evidence quality in medicine commented to the effect that there was ‘a lot of pressure from Wessely and people’. But it is useful to see exactly how this operates.

    The key point of course is the irony, or hypocrisy, around words like transparency and flaws in methodology. The analogy with Mr Trump’s comment about Germany being a serf to Russia is hard to avoid. With regard to ME/CFS a key issue has been the recognition of the lack of transparency and flawed methodology around the PACE trial of CBT and exercise therapy. That recognition is now in peer reviewed journals and has been expressed in Parliamentary debates, but Wessely has consistently championed the trial. The extraordinary thing is that the seven bullet points raised by this pressure group, quote above in your blog, could be tailor made as a critique of PACE and all the other trials of psychotherapy in ME/CFS.

    This activist group likes to give the impression that they have expertise in methodology. Yet in his emails to me Wessely made it clear that either he did not understand the most fundamental issues in trial design required to remove bias or that he wished to give that impression. It is notable that there is nothing of actual substance in the critique they make.

    I find it interesting that you seem to be accused of being under the influence of big pharma – irony again. The documents above make it very clear that the activist group see themselves as ‘stakeholders’ in the same way as pharmaceutical companies and see it is as legitimate to indulge in aggressive marketing of a particularly opaque and worrying kind. GSK and Roche would not have been granted an extra stakeholder meeting, so what is going on here? The parallels in methods, with use of the Science Media Centre, lobbying of the media in general, etc. are striking. (When I met with the BBC about ME/CFS they told me not to say anything because Wessely had already been hassling them.)

    Of course Wessely himself so often seems not to be actually ‘involved’. I am reminded of Hughes Mearns:

    Yesterday upon the stair
    I met a man who wasn’t there
    He wasn’t there again today
    I wish, I wish he’d go away

    We need real transparency and competent analysis of methodology and these things seem peculiarly hard to come by in this area. I am saddened to see that institutions such as The Lancet, the BMJ, and even the MRC do not seem to be able to handle them well. NICE and Cochrane are showing signs of beginning to understand what is going on but there is a way to go.

    The only way to sort this out is to have a full public discussion.

    Best wishes

    Jonathan Edwards
    Professor Emeritus, Dept. Medicine, UCL

    1. Thank you Jonathan. Your reflections are astute and helpful.

      I have been following the PACE trial considerations as best I can. The methodology of this trial seems to me to be neither scientific nor ethical.

      It interests me that it is President Simon Wessely who chooses to make communications “personal”. Again we have seen examples of this by another President who is visiting the UK the noo. My interest is in ethical science.

      Only President Simon Wessely will know if in signing his e-mail to me with “Sink” he meant that I was a “heartsink”.

      aye Peter

  4. Should we bring Sigmund into this Peter!
    Oh alright – he may have had his moments.

  5. Peter – and Jonathan
    We found this last night … ‘education’ for GPs is Scotland – about PESTO (!)

    http://www.nes.scot.nhs.uk/media/3224103/pesto_v2.pdf

    One of the main refs is paper co-authored by Prof Michael Sharpe … of PACE fame:

    https://www.cambridge.org/core/journals/psychological-medicine/article/depression-and-anxiety-in-patients-repeatedly-referred-to-secondary-care-with-medically-unexplained-symptoms-a-casecontrol-study/876935BEF4C5674FDD3894381F30A91A

    I think you will spot the connections …..
    Marion

  6. Thank you for publishing this. It well illustrates what ME sufferers have been up against for the past 30 years. The slightly-veiled threat is serious and the “Wessely School” never hesitates to retaliate against anyone who challenges the party line, including esteemed academics across the pond such as Dr David Tuller. [1]

    It seems that the more the work of Regius Professor Sir Simon and crew is criticized, the more rewards and titles he receives. I wonder just exactly what it will take for his protectors to finally cut him loose?

    [1] http://www.virology.ws/2017/12/23/trial-by-error-bristols-complaint-to-berkeley/

  7. It’s so good that you’re speaking out Peter.
    And thanks for the PESTO link Marion.

    With respect to PESTO and MUS, it really is a no-brainer, isn’t it?

    The NHS must simply stop these difficult, heart-sink patients harming themselves and using up lots of NHS money and resources in the process. And GPs must avoid potentially harmful referrals to secondary care by diverting these troubled individuals to cheap psychological therapies – IAPT and computerized CBT- instead. Of course, we can rest assured that doctors know everything there is to know and that each one practises medicine at 100% reliability, all of the time. Everyone knows that doctors NEVER get anything wrong, misdiagnosis doesn’t exist, or if it does it’s at such low rates it really isn’t worth bothering about. Tests results are wholly dependable, reporting is never subject to error and supposed adverse drug reactions are almost always the figments of patients’ imaginations. (Why else would the ADR reporting rate to the MHRA be so low?) And doctors are so skilled at diagnosing MUS now that a recent paper said they can spot it within the first few seconds or minutes of the consultation. Brillliant! But soon doctors may not need to endure their heart-sink patients for even a few minutes. A computer app could do the diagnosing for them, with newly diagnosed MUS patients whizzed off for CBT before the GPs can say ‘Hey PESTO’. Happy patients, happy doctors. Oh, what a happy world we’ll all be living in. Magic.

    And we know that Professor Sir Simon Wessely has been at the helm, with the RCPsych firmly behind the JCPMH ‘Guidance for commissioners of services for people with medically unexplained symptoms’ as well as his study being the source of the MUS prevalence figures that are quoted left, right and centre to sell the MUS agenda to healthcare professionals and commissioners across the UK. So we’ll know who to thank if, nay when, (a positive attitude is SO important), the UK brims with unparalleled health and we’re all completely bowled over by this much-anticipated, abounding happiness.

    1. Mental health professionals should be concerned about the use of psychology for legitimizing the neglect of patients with complex or poorly understood illness. The ongoing controversy surrounding ME/CFS is the result of this kind of politics. Now the treatment given to ME/CFS patients is being expanded to include everyone with MUS, of which there are far more than ME/CFS patients.

  8. I note that there has been some discussion about my blog-post on:

    https://www.s4me.info/threads/simon-wessely-didnt-want-his-e-mail-on-a-blog-here-it-is-on-hole-ouisa.5001/page-2

    I thought that it might be helpful to explain a little more backdrop. I have registered on ‘Science for ME’ but get this message “You have insufficient privileges to reply here”, so I am not currently able to reply directly.

    The first thing I would like to confirm is that I do not have any “beef” with Prof Sir Simon Wessely. I simply do not share his views and approach to transparency. My interest has long been in over-medicalisation and the potential for any intervention (not just medications) to cause harm as well as benefits.

    I have petitioned the Scottish Government for A Sunshine Act for Scotland. At the time Prof Sir Simon Wessely was President of the Royal College of Psychiatrists and we communicated about the College approach to transparency, which I felt was failing. I should say that I have never met Sir Simon Wessely though I did see him arrive at the International Congress in Edinburgh 2017 where I was peacefully protesting (re Sunshine Act).

    ‘Snow leopard” states: “Peter Gordon then posting the private email exchange is also strange and it is likely there was some sort of prior provocation between them before this current exchange”. This speculation is not correct. I shared this communication because I am of the view that transparency matters in science and in our approach to healthcare overall. Transparency about Medical Guidelines is most important, and a powerful individual, or indeed any powerful organisation should not strive to hide matters important to public health.

    ‘Woolie’ is correct: “I just read Peter Gordon’s letter to the Scottish Parliament here, and it gives some background to Gordon’s concerns. They are largely about the overprescription of antidepressants and other psychoactive drugs in psychiatry and general medicine.”

    ‘Woolie’ states: “So his beef with Wessely is confusing, because Wessely does not seem heavily in bed with pharma”. It is correct that Sir Simon Wessely has not been significantly involved with Pharma, however, in my opinion, in his position of power (as President of my College) he could have helped ensure far greater transparency than we have today. Sir Simon Wessely has shown various views on the place and role of big business in psychiatry and medicine generally

    ‘Emsho’ is absolutely correct that my concerns about this matter have a link with antidepressant dependence and withdrawal effects which can be severe and protracted.

    ‘Emsho’ continues “I’ve been told that patients’ concerns are frequently dismissed and they are being diagnosed with somatic/functional disorders or Medically Unexplained Syndrome (MUS). The PACE trial (certainly in Scotland) is being used as evidence for MUS, and for their symptoms being ignored.” This is indeed my concern and that of many others.

    Both Sir Simon Wessely and his wife Prof Clare Gerada have consistently argued that dependence and withdrawal from antidepressants are generally minor and very short lived. This outlook is at odds with the prescribed harm community.

    I hope this wee summary is helpful.

    aye Peter

  9. I’m not an ME sufferer but I’m very much aware that some ME patients have been seriously harmed by being inappropriately prescribed antidepressants or other psychoactive drugs for their supposed psychosomatic symptoms.

    It’s a concern that patients, (including those with ‘MUS’ and ME), who opt for IAPT psychological/talking therapies could find antidepressant medications being recommended to them at Step 3 (moderate or severe symptoms) and above of the ‘stepped care’ model, but it’s even more worrying that some charts depicting the model have shown ‘Medication’ coming in as an option at Step 2 (mild to moderate symptoms).

    Doctors and NHS commissioners are taught that ‘MUS’ prevalence rates are very high, with 15% – 30% of GP consultations and 50% or more of outpatient visits being attributable to ‘MUS’. As more and more doctors are persuaded to direct or refer their patients to psychological therapies, how many patients will end up on antidepressants and other medications when those therapies fail to resolve their misdiagnosed physical health problems?

    And with a current focus on identifying ‘MUS’ in the elderly population, how many elderly people will be harmed by being prescribed antidepressant drugs? (I understand that elderly people who take antidepressants may be at increased risk of hyponatraemia, especially with SSRIs such as citalopram).

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