Room under the umbrella

Minervation Ltd (Mental Elf) has recently shared an analysis and critique of the following paper stating that it was “deeply flawed and unreliable”:

The analysis of this paper by Dr Joseph Hayes and Dr Sameer Jauhar “established methodological flaws and errors in data extraction” and concluded that it is “difficult to accept the findings with any confidence.” 

The Mental Elf stated that Hayes and Jauhar have “set the record straight on antidepressant withdrawal”.

The authors of this original review paper have since offered a reply – including a wish for all to work together in improving understanding of this issue. I agree, there needs to be room for all under the umbrella of understanding:

“While waiting for the prescribing professions to conduct better studies we hope that all concerned, including those guilty of denial and minimisation in the past, can now work together to acknowledge what thousands of people with direct experience have been trying to tell their doctors for years, to provide full information to people contemplating starting antidepressants, and to lobby for support for the millions trying to withdraw from them.”

Ben Goldacre stated: “Good blog post. But I’d prefer it if the authors did a systematic review themselves. Important issue, lots of patients. I hope this response is only a holding blog. Peer review has a role but is mainly a slow irrelevant circus.”

The sociologist and biologist Patrick Geddes, long since dead, once affirmed his view:

Room under the umbrella (some thoughts):

Hayes and Jauhar state that recognition of withdrawal symptoms from antidepressants in the scientific literature is “not new”. This may be the case, but has this “scientific recognition” correlated, as it should, to the actual experience of those who have been taking antidepressants?

In terms of recognition in the clinical setting, I am even less sure about this. As Hayes and Jauhar point out there may be confusion about what is termed “relapse” and what may be withdrawal symptoms as a result of becoming dependent on an antidepressant. Alistair Campbell recently described his experience, concluding that he has “definitely become dependent” on his antidepressant:

[I M] B A L A N C E :

Notes on imagery used:

Three doves:  From "A Scot Remembered" "Why isn't Patrick Geddes better known? Some say he was a great mind born out of his time. The world wasn't ready for his ideas. P.G. was a Holist. He saw education as a coming together of experiences and ideas to create an integrated system much greater than its parts. He explained this as starting with Sympathy or understanding of ones fellow man and the environment, followed by the coalescing( Synergy ) of disciplines of learning and finally a building up ( Synthesis) into a connected whole. He symbolised the three Ss as three Doves, the recognised symbols of Peace but his ideas fell on deaf ears. Narrow specialisation , which he abhorred, was the route to academic recognition. He did not conform to the mores of academia and to his contemporaries his thinking was undisciplined, eccentric and unworthy of their respect."

Mortar and Pestles: I used these as symbols for over-medicalisation. One of my earliest memories was looking up from my pram to see a golden mortar pot. I assumed it was full of sweets and could not understand why it was out of my reach.

Hayes and Jauhar expressed concerns that this published review on antidepressant withdrawal was “heavily featured in the media” but make no mention of the clarion call, seemingly coordinated by the Science Media Centre, on the publication of this Lancet meta-analysis:

The reporting of this meta-analysis carried headlines such that “more people should get pills to beat depression” and that it “finally puts to bed the controversy on antidepressants”. Neither the authors nor the experts giving their reaction mentioned, at least in what I read and watched, that the studies included were on average only 8-12 weeks in duration. There was also no discussion of potential harms associated with antidepressants: such as dependence or withdrawal.

Recently published Scottish Government figures have confirmed that almost 1 in 5 of our population are now taking antidepressants. The prescribing rates have increased year-on-year for the last decade: this would seem to reflect the reality that antidepressants are being taken far longer than available evidence can offer scientific support for. It is reasonable then to question how “realistic” such prescribing is?

I share in the determination for science, as Robert K Merton once described, to be “disinterested”. Hayes and Jauhar rightly question ideological or intellectual conflicts of interests. These potential conflicts apply to all academics and scientists. Jauhar argued otherwise in a paper co-authored with the President of the British Association of Psychopharmacology.

I have campaigned for Sunshine legislation for much of the last decade. My argument is based on robust evidence confirming that competing financial interests can lead to doctors recommending worse treatments for patients.

The Editor-in-Chief of the BMJ has recently stated that “paid opinion leaders are a blot on medicine’s integrity, and we should make them a thing of the past.”

Here are some of the paid opinion leaders in UK psychiatry [I have used information available in the public domain to construct visual summaries of the competing interests of some key opinion leaders. I have done so in the spirit of the relevant guidance of the Royal College of Psychiatrists].

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I have written to a number of UK bodies who have a leadership role in healthcare to ask whether they support Sunshine legislation or not? I have had limited responses so far but have received this from the Science Media Centre. I have also spoken to one of the Managing Directors of Minervation Ltd (Mental Elf) who asked for more time to consider this question “because to be honest [he did] not know much about it”. 

In the section, “Implications for practice” Hayes and Jauhar conclude:

“Whilst withdrawal effects are high for certain drugs (paroxetine, venlafaxine), when stopped abruptly, this happens very rarely in clinical practice and guidelines are in placed to address this. Furthermore, if people do experience withdrawal symptoms, there are treatments available, such as cross-titrating to a drug with a longer half-life, less likely to cause withdrawal, such as fluoxetine, followed by tapered withdrawal.”

This has not been my experience as an NHS psychiatrist of 25 years. It has also not been my personal experience.  However, one senior member of the Royal College of Psychiatrists has stated publicly that for antidepressant withdrawal: “there already is a solution – switch to fluoxetine.” If this is the case one wonders why this issue has led to petitions to both the Scottish Parliament and the Welsh Assembly?

I want to close with this thought from “The Muse” by Jessie Burton:

3 Replies to “Room under the umbrella”

  1. “….In terms of recognition in the clinical setting, I am even less sure about this. As Hayes and Jauhar point out there may be confusion about what is termed “relapse” and what may be withdrawal symptoms as a result of becoming dependent on an antidepressant. Alistair Campbell recently described his experience, concluding that he has “definitely become dependent” on his antidepressant:”

    I have been on Venlafaxine, mainly XR, for over 18 years. Two years ago I tried a careful taper from 225mg using advice from an AD website.
    A couple of months ago I crashed at c56mg after thinking I was doing well. I had overshot my min. therapeutic dose, I am guessing.
    Have been slowly updosing at 12.5mg increments and am currently at 112.5mg and may be a bit better.
    I did well for years at 150-187.5mg. I have realised this by examining my diaries, photography, toutings, pursuits, enthusiasm for my interests, etc.

    I have quite a detailed set of data going back years for myself. I am a retired middle-grade scientist. DOB 27/6/45. Age 73.

    After the crash, I realised coming off ADs was probably not for me. I have concluded that childhood and teenage emotional traumas (PTSD?) have remapped my brain?? and so have to face the rest of my life on some amount of AD.
    I heard my father dying in our house of a spontaneous pneumothorax in 1954 when I was 9 years old. A relocation to another primary school in a city a few hundred miles away and an upbringing as an only child with a domineering mother was tough.

    Anyway, as for today, anything is better than the existence I have been going through during several months of the past two years, so I am quite philosophical about having to “keep taking the tablets.”

    Best regards to you Dr Gordon.

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