The influence of paid opinion leaders on the prescribing of antidepressants in the UK

I submitted two rapid responses to the BMJ in relation to this published letter: Reversing the rate of antidepressant prescribing:

I divided my responses in two so that the word count for each was below 600 words. Unfortunately the BMJ replied to state that they “haven’t the resources on BMJ Responses to check” my submissions and in particular the timeline that formed my second response.

I replied to the BMJ as follows:

“I am naturally disappointed that my recent responses may not be published online by the BMJ. Thank you for your suggestion of an Analysis piece. Having looked at the guidance I am not sure this format fits with the evidence I am trying to share. However, I do believe that this is a very important topic and will continue to do my best to maintain a high profile for the issue of competing financial interests.”

Below, I share my responses in full. I am hopeful that those who are on social media might share them widely.

---

British Psychiatry is heavily influenced by opinion leaders

I see that there have been a number of responses to this letter: Reversing the rate of antidepressant prescribing [1]. I worked as an NHS psychiatrist for over 25 years and as part of my continuing medical education regularly came across the work of a number of the respondents [2], [3].

British Psychiatry is heavily influenced by opinion leaders who are often paid by industry. These opinion leaders are in positions where they can significantly influence prescribing of psychiatric drugs. Furthermore, this group determinedly shape and form the overall narrative arguing that they are free from “ideology”. Yet, the exact basis of their “joint working” is generally opaque. This may reflect a wish to maintain a position of medical authority that comes from science that is perceived as independent from outside interests.

I have submitted a response titled “The influence of paid opinion leaders (POLs) on the prescribing of antidepressants in the UK – a timeline of some key publications” [taken from the public domain and with all available citations provided].

In October 2018, the Editor-in-Chief of the BMJ, Fiona Godlee said: “We don’t let judges or journalists take money from the people they are judging or reporting on: we shouldn’t let doctors do this either. Paid opinion leaders are a blot on medicine’s integrity, and we should make them a thing of the past.” [4] However POLs who generally control the narrative in relation to psychiatric drug prescribing continue to be very much of the present.

References:

[1] Letter: Reversing the rate of antidepressant prescribing. Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. 5 December 2023. BMJ 2023;383:p2730.

[2] Rapid Response: A Prescription Error. 12 December 2023.

[3] Rapid Response. 18 December 2023.

[4] GSK will resume paying doctors to promote its drugs after policy U turn. 3 October 2018. BMJ 2018;363:k4157.

---

The influence of paid opinion leaders [POLs] on the prescribing of antidepressants in the UK – a timeline of some key publications:

[i] 1992 – 1996: The Defeat Depression Campaign. A 5-year campaign aimed at enhancing public awareness and attitudes and providing professional education [2]. Primary sponsor was the Pharmaceutical Industry.

[ii] 17 March 2003: “Inquiry thrown into doubt over members’ links with manufacturers” [3]: POLs jointly fronted the promotional press launch of Seroxat after it won a licence to be prescribed for social anxiety disorder.

[iii] 26 May 2014: Attacks on antidepressants: signs of deep-seated stigma? [4] Four out of five of the authors of this correspondence are known to have repeatedly worked for the pharmaceutical industry and three out of five are career-long POLs.

[iv] 23 June 2017:  Minutes of the Psychopharmacology Committee meeting of the Royal College of Psychiatrists outline the alliance between the Royal College of Psychiatrists and the British Association for Psychopharmacology (BAP) in providing continuing medical education. The Minutes state: “RCPsych Psychopharmacology Committee and the BAP usually jointly organised 6 or 7 sessions at the International Congress and it was important that this continues.” [5] This is how BAP describes its relationship with Industry [6] “The BAP is a learned society and registered charity that is tripartite in origin and nature and brings together members from pre-clinical neuroscience, clinical psychiatry and industry.”

[v] 7 April 2018: Headline on the front page of the TIMES: “More people should get pills to beat depression” with subtitle “Millions of sufferers would benefit, doctors told” [7]. This was reporting of the following review article: Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis [8].  The lead author of this review was quoted: “Undertreated depression is a huge problem and we need to be aware of that. We tend to focus on overtreatment but we need to focus on this. A spokesperson for the Royal College of Psychiatrists [and POL]: “This meta-analysis finally puts to bed the controversy on antidepressants” However, the experts giving opinions on the meta-analysis did not make clear that this review was based studies of short term antidepressant prescribing (8-12 weeks) for major depressive disorder.

[vi] 1 February 2019: Antidepressants, what’s the beef? [9] Written by two career-long POLs who featured on BBC Panorama “Who’s paying your Doctor” [10]. Today, both remain hugely influential in terms of Continuing Medical Education [CME].

[vii] 30 May 2019: Royal College of Psychiatrists CME conference was held in London including “Invited Lecture” given by a POL entitled “Myths about mood disorders” [11]. The same POL provided an “expert opinion” published by the Science Media Centre [12]: “Antidepressants, like all drugs, should be taken as per best advice. So-called withdrawal reactions are usually mild to moderate and respond well to simple management. Anxiety about this should not obscure the real benefits of this type of treatment.”

[viii] 11 April 2022: Increased global integration in the brain after psilocybin therapy for depression. [13] POL stated: “Even the best-performing antidepressant drugs show modest efficacy, non-negligible side effects, discontinuation problems and high relapse rates, highlighting the need for new, improved treatments”. However, in 2014 the same POL had stated in Attacks on antidepressants: signs of deep-seated stigma? [14]:  “Antidepressants have an impressive effect size in the treatment of acute cases of depression” and “antidepressants have an impressive ability to prevent recurrence of depression … which makes them one of the most effective of all drugs”.

References:

[1] Letter: Reversing the rate of antidepressant prescribing. Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. 5 December 2023. BMJ 2023;383:p2730.

[2] The Defeat Depression Campaign: psychiatry in the public arena. June 1997. Am J Psychiatry. 154 (6 Suppl) 59-65

[3] Drugs inquiry thrown into doubt over members’ links with manufacturers. 17 March 2003.  The Guardian.

[4] Attacks on antidepressants: signs of deep-seated stigma? Lancet, Vol 1, Issue 2, P102-104.

[5] Minutes of the Psychopharmacology Committee meeting of the Royal College of Psychiatrists. 23 June 2017: The Royal College of Psychiatrists used to make minutes of these committee meetings accessible to the public. However, they no longer do.

[6] The British association for Psychopharmacology [BAP]: Relationship with Industry. 

[7] More people should get pills to beat depression. The Times. 22 February 2018.

[8] Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. 7 April 2018. The lancet. Vol 391, Issue 10128, P1357-1366.

[9] Antidepressants, what’s the beef? February 2019. Acta Neuropsychiatrica, Volume 31, Issue 1.

[10]BBC Panorama: Who’s paying Your Doctor? 27 April 2014.

[11] Royal College of Psychiatrists Conference, London. 30 May 2019. Lecture: “Myths about mood disorders” RCPsych no longer seem to make available the programme for this accredited educational conference. The original link [no longer active] However the original programme can be accessed via the Wayback Machine.

[12] Science Media Centre: Expert reaction to Royal College of Psychiatrists position statement on antidepressants. 30 May 2019

[13] Increased global integration in the brain after psilocybin therapy for depression. 11 April 2022. Nature Medicine, 28, pages844–851.

[14] Attacks on antidepressants: signs of deep-seated stigma?26 May 2014.  Lancet, Vol 1, Issue 2, P102-104