Submission on PE01651: Prescribed drug dependence and withdrawal

As an NHS Psychiatrist who has worked in Scotland as a Consultant for over 15 years I want to offer my full support for this petition.

Recently at a Cross Party Group meeting held at the Scottish Parliament it was stated that “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.” This was said without acknowledging that these statements cannot be made with absolute certainty.

I have found that my profession in Scotland seems to resist evidence of experience and at the same time prioritise the opinions of experts.

Potential for Expert Bias (one):
There is evidence that establishes that senior Scottish psychiatrists, who have provided expert input to Scottish Government strategies, and who have been involved in developing National prescribing guidelines, have had significant financially-based vested interests.

Potential for Expert Bias (two):
It is worth perhaps pointing out that Scottish Psychiatry has been traditionally orientated around biological determinants of mental health. Like myself, many academics have concluded that Scottish psychiatry lacks real-world, pluralistic breadth to the science of the mind and brain. Across the border, in England and Wales, the approach is far less reductionist. This includes the involvement of experts whose interests are not solely focussed on the bio-medical determinants of mental health.

I do prescribe psychiatric medications including antidepressants but I do not agree with the ‘experts’ that prescribing in Scotland is “conservative”. 1 in 7 Scots are now taking antidepressants.

Appropriate and informed prescribing is what we seek where there is open discussion about the potential benefits and potential harms of such treatments. This and an honest consideration that for many medications we cannot be certain of long-term effects.

                      Dr Peter J Gordon
                      GMC number 3468861

May it be granted the older you are

On the 26th of April 2016 I attended the Cross Party Group on Mental Health and Older People, Age and Ageing, held at the Scottish Parliament. The following is an  account of my experience of this meeting and some reflections on conversations that have followed it.

At the end of this post are included two papers that were submitted ahead of the Cross Party meeting: a paper by me entitled “May it be granted the older you are” and a paper by Mr Hunter Watson entitled “Psychoactive Medications”.

I have been to quite a number of Scottish Parliamentary Committee meetings but this was the first Cross Party Meeting that I have attended. How welcome it was to see such a good turn out with a packed committee room. I am inclined to conclude that this indicates how important it is that we value our older generation. It was however unfortunate that other parliamentary business meant that various parliamentarians had to absent themselves.

I was  keen to attend this meeting for a number of reasons. Having an interest in the Scottish Government’s “Ten Year Vision” for Mental Health I had attended one of its consultation events in Edinburgh and had also submitted a written response. There were  574  written responses in total, which again seems most encouraging.

Given that opportunities for anyone to raise discussion, at parliamentary level, about the Scottish Government’s ‘Ten Year Vision’ may not come along very often, I felt it was important, as the only NHS psychiatrist for older adults at this Cross Party meeting, to do my best to put forward the experiences of my patients.

I was very impressed that the convener, Sandra White, MSP made sure that as many voices as possible were heard at the meeting. I wrote to thank her for this.

I was particularly struck by the compelling and worrying testimonies of Rosemary Carter and Dianna Manson whose experiences as older adults with mental health issues remind us starkly how important it is that policy makers consider very carefully the consequences of visions set for the years ahead.

Rosemary Carter highlighted her experience of how the dominance of cognitive assessments in my profession has reduced capacity to care for those who have non-cognitive mental ill health. As a professional working in this area I share her concern and am of the view that Rosemary is far from alone in her experience. When the Dementia Strategies and Targets were first introduced in Scotland from 2010 onwards, it was my concern about this potential for inverse care, and for increased stigma associated with ageing, that led me to advocate publicly for a timely approach to the diagnosis of dementia. I did so at a time when this approach had no support whatsoever from policy makers, healthcare or the Mental Welfare Commission.

I thought that Angela Dias of “Action in Mind” spoke with clarity and genuine concern about what she termed “institutional discrimination” relating to older adults with mental health issues living in Scotland today.

Mr Hunter Watson’s concerns about human rights for older adults do, in my opinion, need to be carefully considered.

The Principal Medical Officer for Scotland, Dr John Mitchell, acknowledged several times the evidence that those with chronic mental health disorders die 15-20 years earlier than those who do not. He stated at this meeting that this is a “huge finding, a universal finding, a huge inequity”. Academics are increasingly of the view that one of the potential reasons for such early death has been the prescribing of psychiatric medications. This is why I mentioned a number of times at the meeting the widely gathered evidence (PE1493, Sunshine Act for Scotland) that the pharmaceutical industry continues to have a significant role in the “education” of Scottish doctors in the prescribing of psychiatric medications.

I thought the presentation by Dr David Christmas was most interesting and share his concern that there is an imbalance in research studies across the age ranges. I raised a number of questions with Dr Christmas because he works as a “super-specialist” and so deals with a very select group of patients.

At the Cross Party meeting Dr Christmas stated that “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.” He did so without acknowledging that these statements cannot be made with absolute certainty.

I have attended a wide range of GMC-required Continuing Medical Education (CME) and so over the years have found that I have attended a number of educational talks given by Dr David Christmas. He always carefully talks through his declarations of interest which for at least the last five years do not  include any financial interests other than his employment with NHS Tayside as the Clinical lead of the Advanced Intervention Service.

Dr Christmas is a member of the Psychopharmacology Committee of the Royal College of Psychiatrists. The Chair of this most influential committee (in terms of the prescribing of psychiatric drugs) is Professor Allan Young, a “key opinion leader”. Professor Allan Young declares his extensive financial interests as follows: “Paid lectures and Advisory Boards for all major pharmaceutical companies with drugs used in affective and related disorders” . A similar key opinion leader, Professor Stephen Stahl, gave a keynote talk at the British Association of Psychopharmacology in 2015. As he is American, and they have a Sunshine Act, it is possible to establish Professor Stahl’s earnings from promoting psychiatric drugs. When last looked at, this was more than $3.5 million dollars. In the absence of a similar Sunshine Act in the UK we cannot establish the scale of payments made in the UK.

Dr Christmas has given educational lectures alongside Dr Hamish McAllister-Williams who is also a member of the Psychopharmacology Committee of the Royal College of Psychiatrists (RCPsych), and who was appointed in 2012 as Director of Education for the British Association of Psychopharmacogy (BAP).

Dr McAllister-Williams declares a wide range of financial interests with the Pharmaceutical Industry. Dr McAllister Williams is “a major contributor” to the RCPsych and BAP Continuing Professional Development programme.

It was with this knowledge, of the influential position that Dr Christmas has in terms of the education of UK psychiatrists, that after the Cross Party Meeting I wrote to ask Dr Christmas to ask if he might support a Sunshine Act for Scotland?  At the meeting Dr Christmas took time to carefully address other biases (which I share his concern about) but did not do the same for the financial biases that may affect the advice given by key opinion leaders. The same potential exists for research itself.

In my correspondence with Dr Christmas I  reminded him that I prescribe both antidepressants and antipsychotics but explain to patients that the best evidence we have is generally based on short-term studies and that all interventions (including psychological interventions) can have both benefits and harms.

I have  confirmed with Dr Christmas that I share his determination to seek science that is as objective as possible and that this means that I realise that biases do indeed come in all forms and not just financial. I simply argue that science should be based on transparency or it ceases to be science. My view is that it is not necessarily a bad thing if doctors are paid for their time and expertise working outwith the NHS. For example, working for NICE, or giving expert views to court. However, when a doctor has a financial “conflict of interest”, this can affect the treatment decisions they make, or recommend. These conflicts cannot be entirely avoided, and in many cases they are entirely reasonable. However, it is important that information is available on which companies have paid a doctor, so that colleagues and patients can decide for themselves what they think. For example, there is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

I have also discussed with Dr Christmas the view that proportionality of understanding should come in words as well as numbers and  that the quantitative and qualitative require ‘parity of esteem’.

In summary, I thought the Cross party meeting on Mental Health, Ageing and Older People was an excellent opportunity for a range of voices to share their thoughts and experiences. Such involvement is to be commended and I hope that both my profession and policy makers of all sorts may agree.

Dr Peter J. Gordon

(writing in my own time)

GMC registration: 3468861

Member of the Royal College of Psychiatrists: number 12351

I have worked in NHS Scotland for over 25 years and I am employed 
with NHS Lothian as a Consultant in Psychiatry for Older Adults. 
As well as being a doctor and scientist, I am a philosopher, 
ethicist, and artist.

 

‘May it be granted the older you are’

Prepared to share with the Cross Party Group on Older People, Age and Ageing ahead of the meeting on the 26th April 2017

In this summary I will present original articles, reports and writing. I wish to keep my words spare.

William H. Thomas said this in 2004 in his book “What are Old People For?”:

On the 1724 ruin of Mavisbank (considered as Scotland’s finest ruined building) and carved on the sculpture “The Ageing Stone” by Dr Peter J. Gordon:

May you grow old either never or late,
and that you experience earthly changes late.
May what the numerous ages erode be restored intact,
may it be granted that the older you are,
the more beautiful you may shine.

[Dr Peter J Gordon was formerly a Trustee of Mavisbank House, Loanhead, Edinburgh.]

Ballatt and Campling in their acclaimed book (2011) “Intelligent Kindness” offered this concern about current approaches to healthcare:

I have argued in a number of publications that prevailing approaches in medicine, and particularly a primary focus on biomedicine may risk this outcome for our older generation:

The Scottish Government and Alzheimer Scotland had this recent four-page spread in a National newspaper:

The Scottish Government has indeed made progress with dementia care but we should be wary of repeated statements made by them that this is “world leading”.

Barak Obama, when President of the United States, said:

Scotland is a relatively small country and this may be one reason why biomedical determinism has prevailed without challenge. This approach to mental wellbeing has its place. I have reasoned in a number of publications, that unless philosophy is irrelevant, then biomedicine should not be the only determinant to wellbeing.

Owen Jones, in his 2014 book “The Establishment” insisted:

Personally I have very much valued the views and writings of individuals like Mr Hunter Watson and Mrs Chrys Muirhead. It disappoints me to have witnessed the ways that those in genuine positions of power have sometimes treated them. Simply because their views may not be shared.

Prescribing of psychotropic medications (of all types) has been rising year-on-year in Scotland for the last decade (ISD figures, Scottish Government). Rising in all age groups: including our children and our older generation. Reporting on this on the 5th October 2016, The Scotsman had as its front-page headline “Prescriptions for mental health drugs at 10-year high”.

Annette Leibing in an Editorial in Cult Med Psychiatry explored the origins of the widely used label/acronym “BPSD”:

One of the consequences of this has been the very wide practice of prescribing ‘off-label’ of antipsychotics in Scotland to those living with dementia. Unfortunately this wide practice has always lacked evidence for the “appropriateness” of such prescribing:

Promotion of “off-label” use of drugs is still widespread practice in the UK and, if anything, has become more embedded since the introduction of GMC required ‘Continuing Medical Education’ (CME):

The above was the concern of the Royal College of psychiatrists in 2005 (twelve years ago). However the Royal College of Psychiatrists has stated recently that this is “now a thing of the past” and that psychiatry is “puritanical” in its relationship with the pharmaceutical industry. Unfortunately real-world evidence does not support this statement (see the wide-ranging evidence gathered for ‘A Sunshine Act for Scotland’ )

Dr Catherine Calderwood, Scotland’s Chief Medical Officer is to be commended for her initiative Realistic Medicine. I have presented the reasons to the Scottish Government why a Sunshine Act for Scotland must be a necessary part of this.

[For instance: If we had a Sunshine Act perhaps the MESH scandal and so much harm might have been avoided.]

Dr Margaret McCartney, Glasgow GP, author, BMJ columnist has outlined the harmful consequences of Industry being in the driving seat. One aspect of this is ‘inverse care’. More than two years on since Dr McCartney wrote this and we find that no NHS Board area in Scotland is achieving more than 54% of the “guaranteed” Post-Diagnostic Support:

More than two years ago this “Change Paper” was published in the British Medical Journal. Professor Burns is the National Clinical Director for Dementia in NHS England and Wales:

In response, I submitted this published rapid-response to the British Medical Journal:

I welcome this “change page”. [1]

The authors describe the routine prescription, off-label, of 
antipsychotics to our most vulnerable elderly. At a recent 
international conference one presentation referred to the estimate 
that “2/3rds of current UK prescriptions for antipsychotics in 
people with dementia are inappropriate”.[2] These reports remind us 
that those living with dementia are often considered to lack 
“capacity” and their voice is easily lost.

My previous correspondence to the BMJ has demonstrated my view that 
our profession should not be “educated” by commerce or industry. 
[3]

In 1999, as a doctor in training, I was handed a document by my 
trainer. This I was told was “the way forward”. The document had an 
acronym: “BPSD”. I had not heard of “BPSD”. I learned that this 
acronym stood for “Behavioural and Psychological Symptoms 
in Dementia”.I accepted it with little thought. The comprehensive 
BPSD document was produced by Pharma: though at the time, and for 
almost a decade thereafter, I was not aware of this fact.

I am aware that a number of NHS guidelines are in existence for the 
treatment of “BPSD”. [4] Haloperidol, in lowest possible dose, is 
generally the drug recommended. My concerns over prescribing of 
antipsychotic drugs like Haloperidol in a frail elderly population, 
led me to raise a petition for a “Sunshine Act” with the Scottish 
Government. [5]

It has been my experience that marketing activity by the 
pharmaceutical industry, and also “education” by key opinion 
leaders paid for by the pharmaceutical industry, have in the past 
encouraged the off-label use of antipsychotic drugs. Until we 
acknowledge this mechanism, we risk losing the opportunity to 
minimise the harm of such an approach.

References 1-5

Four months later this research was published:

It should be noted that antipsychotics also can cause side-effects (morbidity) as well as increasing risk of mortality. Such side effects include: parkinsonism, sedation, mental dulling, excess salivation, weight gain, cardiac disturbances and hormonal dysregulation. This is why, as an NHS doctor for older adults, I use antipsychotics as sparingly as I can and generally when all other options have reasonably been tried. If I do prescribe antipsychotics I try to do so for as short a period as possible.

The SIGN 86National Clinical Guideline” on “Management of patients with Dementia” was published in 2006. A review of national guidelines on dementia, published in 2013, established that this was found to be almost the worst national guideline for dementia in the world (certainly in terms of consideration of ethics)

I have written about my concerns that financially vested interests may have played a significant part in the development of SIGN Guideline 86 on Dementia:

Last year Sign 86 Guideline was withdrawn. There has been no replacement – despite the promise made within SIGN 86 – to have it reconsidered by 2011.

The following slides consider failures of governance for National Guidelines such as SIGN:

One of my interests is in ethics. I share the ethicists’ view that we all may suffer if our shared determination scientific objectivity is compromised for vested reasons. It was this consideration that led me (in 2013) to petition the Scottish Parliament to consider introducing a Sunshine Act for Scotland:

My petition was closed in February 2016 after wide gathering of evidence and a Public Consultation.

The public consultation revealed that the Scottish public support the petition and that in majority they would like to see all payments made to doctors, healthcare workers and academics to be publically declared on an open, central register.

More than a year on since this consultation was concluded and the public has had no meaningful update from the Scottish Government.

In the Observer newspaper of 1st October 2016 an Editorial our older generation ended:

I also want to end by celebrating the real value of our older generations.

This was a rapid response to the British Medical Journal by myself that was published 2nd September 2015

The contributions of those “retired” often prove invaluable:

Yesterday I was at a consultation event held by Healthcare 
Improvement Scotland which sought wider views on a proposed 
national approach to “Scrutiny” of health and social care in 
Scotland (1). At the meeting I met a number of individuals who had 
been designated “retired” on their name badge. I was not surprised 
to find that during the course of the consultation event, the 
contributions of those “retired” proved to be invaluable.


Returning home on the train I thought about this a little more. 
Names like J K Anand, L Sam Lewis and Susanne Stevens, all regular 
submitters to the BMJ rapid responses came into my mind. All 
describe themselves as “retired” and one happily calls himself 
“an old man”. The contributions by retired folk have always struck 
me as having a different quality to those by people who are still 
employees of today’s NHS. In “retirement” there may be a greater 
freedom to ask questions of prevailing approaches. Our older 
generation also has great experience which should be considered 
as “evidence” in itself.


Yet in my job as a doctor for older adults, I see the world around 
me as seeming to do its best to reduce our elders. The language 
used in discussing our elders commonly denotes some sort of loss. 
For example the “guru” of Healthcare Improvement Don Berwick talks 
about the “Silver Tsunami”. Other healthcare leaders talk of 
“epidemics” and “challenges”, implying that our elders are a burden 
to younger generations. To address these “challenges” the 
healthcare improvers, it seems to me, are devising shortcuts. 
Today these are often termed “tools” and may be part of “toolkits”. 
I have even heard healthcare improvers discussing the need to 
“invent” a “tool” for patient centredness. I think our elders, 
or those “retired”, might consider this to be particularly 
ridiculous.


So I would like to say three cheers for the “retired” folk. 
To discourse they bring wisdom, to the prevailing methodologies 
they are more willing to ask critical questions, and when it comes 
to cutting through to what matters, being true to oneself, 
our elders are superior to many, if not most, policy makers.

References 1 and 2


 

Mr Hunter Watson also submitted a paper ahead of the Cross Party Meeting on Mental Health and Older People, Age and Ageing. It is included below:

In the report entitled “Remember, I’m still me” psychoactive medication is described as “medicines used to treat behavioural symptoms, like agitation, verbal and physical aggression, wandering and not sleeping”. From this description it seems clear that psychoactive medication is regarded by some as medication which can be used as chemical restraint rather than for the purpose for which it was developed.

That report, which was published in April 2009, was based upon what was found when the Care Commission and the Mental Welfare Commission made joint visits to a sample of 30 care homes in Scotland. The authors observed that “While we saw some examples of good practice, our findings reveal that overall, care in Scotland’s care homes needs to improve significantly in order to meet the needs of people with dementia who live in them”.

The report also noted that “Although most staff were aware of different types of therapies recommended for caring for people with dementia, they told us they were not using them or encouraging them to be used as they did not feel their knowledge was sufficient and they did not have enough time.”

In May 2014 there was published a report entitled “Dignity and respect: dementia continuing care visits”. This report was based upon what the Mental Welfare Commission found when it visited 52 NHS units providing longer-term care for people with dementia. Among its findings were the following:

84% of people were on at least one psychotropic medication 
(i.e. psychoactive medication) with 30% on three or more, 
in many cases without evidence of regular reviews

175 people (52%) were taking anxiolytic medication, mainly 
Diazepam or Lorazepam, with 65 of the 175 (37%) receiving this 
on a regular basis. This level of use is disturbing and is much 
higher than the level of use we found in Remember, I'm still me 
where only 19% of people with dementia in care homes were 
prescribed anxiolytic medication. The British National Formularly 
(BNF) states "Anxiolytic medication should be limited to the 
lowest possible dose for the shortest possible time".

166 people (45%) were taking antipsychotic medication. While this 
may be helpful in relieving symptoms such as hallucinations, 
delusions, agitation or aggression, there are known risks for 
people with dementia. All antipsychotic medications increase 
the risk of stroke and death, many can impair mobility and 
increase the risk of falls.


Although people with dementia in NHS care may present with more 
challenging and complex problems than people with dementia in other 
care settings, staff skills and knowledge and staff numbers should 
be better. We were concerned at the high usage of antipsychotic 
medication often in combination with anxiolytics or sedative 
antidepressants.

In October 2016 there was issued a National Statistics Publication for Scotland entitled “Medicines used in Mental Health”. It provided statistics for the years 2005/06 to 2015/16. Among the facts contained therein are the following:

All NHS Boards show increased prescribing of antipsychotic drugs 
since 2009/10.

The total number of prescription items dispensed for psychoses and 
related disorders increased between 2014/15 and 2015/16 ...  
This follows a gradual increase over the last ten years. 

The majority of the drugs used in the treatment of psychoses and 
related disorders are antipsychotic drugs.

In June 2010 there was published a document entitled Scotland’s National Dementia Strategy”. This document made clear that the Scottish Government was committed to “ensuring that people receiving care in all settings get access to treatment and support that is appropriate with a particular focus on reducing the inappropriate use of psychoactive medication …”

In May 2013 there was published a document entitled “Scotland’s National Dementia Strategy: 2013 – 16”. In this document it was stated that “The first Dementia Strategy identified that a key driver to ensure care and treatment is always safe, effective and appropriate is working with partners to reduce the inappropriate prescribing of psychoactive medication for people with dementia”. In order to try to achieve this goal an expert working group was asked “To agree and recommend a national commitment on the prescribing of psychoactive medications (excluding cognitive enhancers), as part of ensuring that such  medication is used only where there must be a likelihood of benefit to the person with dementia and where there is no appropriate alternative”.

In a 1998 edition of the International Journal of Geriatric Psychiatry (No 13) there appeared an article entitled “Medication Use in Nursing Homes for Elderly People”. In the summary it was stated “Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. (Disorders caused by medication.) Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions (i.e. antipsychotic prescriptions) for the treatment of behavioural disturbances have been significantly reduced and non-pharmacological  strategies aimed at ameliorating behavioural disturbances have been proposed.”

In the editorial of the BMJ of 1 April 2006 it was stated, with reference to an article entitled “Managing challenging behaviour in dementia”, that “… the behaviour of staff … may play a central role in the manifestation of challenging behaviours in patients … a new culture of dementia care should focus on meeting individual patient’s needs rather than on restraint.”

On 3 June 2011 I was sent from the USA a copy of an article entitled “The wrong drugs in nursing homes. Too many antipsychotics” The article was written by Daniel Levinson, the inspector general in the Department of Health and Human Services. Within that article it is stated that “Researchers found that 88 percent of the time, these drugs (antipsychotics) were prescribed for elderly people with dementia. This is precisely the population that faces an increased risk of death when using this class of drugs, according to the FDA.The report didn’t investigate why patients with dementia are prescribed antipsychotic drugs so often. But a series of lawsuits and settlements that my office helped to bring about suggests that many pharmaceutical companies have improperly promoted these drugs to doctors and nursing homes for many years.”

Observations and recommendations:

The production of dementia strategies has been ineffective in 
reducing the prescribing of life-threatening antipsychotic drugs 
to people with dementia in care homes and hospitals. The Scottish 
Government should, therefore, agree that, as recommended by the 
Mental Welfare Commission, there be a wide review of mental health 
and incapacity legislation when the place of learning disability 
and autism in current mental health legislation is reviewed. 
When carrying out that review full account should be taken of 
the Convention on the Rights of Persons with Disabilities.

Guidelines should be produced for the use of antipsychotics and 
otherpsychoactive drugs for people with dementia. 

These guidelines should take full account of the recommendations in 
the British National Formularly. 

Note should be taken of the fact that the guidelines in SIGN 86 
have now been withdrawn since they became out of date.

New National Care Standards for Care Homes for Older People 
should be produced. These new standards should not suggest 
that medication could be used as restraint in response to 
"restless or agitated behaviour" as do the existing care standards. 
This suggestion positively encourages care home staff to request 
that a doctor prescribes an antipsychotic for a resident whose 
behaviour is perceived as challenging. Unfortunately some doctors 
are too ready to accede to such a request and do not properly 
consider whether the known risks outweigh the potential benefits 
nor attempt to obtain the informed consent of the patient. 
There seems to be an incorrect assumption by some that care home 
residents, especially those with dementia, would be incapable of 
passing the recognised test of capacity to make a treatment decision.

New regulations should specify that doctors must take due account 
of prescribing guidelines when they prescribe antipsychotics to 
care home residents and also that they must give a written 
explanation of any decision to do this. The care inspectorate 
should confirm that due account has been taken of prescribing 
guidelines and also that acceptable written explanations have been 
provided. The regulations should specify sanctions which could be 
taken against care homes in which there has been evidence of an
excessive and inappropriate use of antipsychotics or other 
psychoactive drugs

It should be recognised that in Scotland, as in the USA, 
pharmaceutical companies could have been improperly making payments 
when marketing their psychoactive drugs as suitable for use in the 
treatment of care home residents and others. 

The Scottish Government, therefore, should make it mandatory for 
doctors, healthcare workers and academics to disclose publicly all 
payments from the pharmaceutical industry. 

Peter Gordon, a consultant in old age psychiatry, submitted 
petition PE1493 to the Petitions Committee in the hope that it 
would lead to the Scottish Government agreeing to enact the 
necessary legislation which he suggested could be named the 
Sunshine Act. However, in an email dated 14 April 2017 sent to 
the Minister for Mental Health and others he stated 
"A year on and there has been no meaningful public update 
from the Scottish Government on PE1493 and a Sunshine Act".

The Scottish Government should give serious consideration to 
Peter Gordon's proposal.

Caring for elderly people with dementia is a demanding task but the 
care homes which have the responsibility for their care are 
commonly under-staffed and under-funded. Such homes are unable to 
pay staff sufficient to ensure that they do not leave for better 
paid and less demanding work elsewhere, such as in a supermarket. 
The consequence is that in some care homes there is a high turnover 
and hence a lack of properly trained staff. In these circumstances 
it is not surprising that care homes resort to the use of 
psychoactive medication when residents present problems.

It should be recognised that in order to ensure that people with 
dementia are properly cared for more resources must be devoted to 
social care and that, if necessary, taxes should be raised to 
achieve this.

Gilbert Farie Revisited

I made this film 5 years ago.

In the five years that have passed since making, prescribing of antidepressants has risen from 1-in-9 Scots to 1-in-7. My view is that this is most unhealthy.

Time moves on and I would perhaps change a few words in this film. That said I feel that this film remains an important presentation:

Were we asleep at the wheel?

At the beginning of June 2008 I sent an e-mail to Dr Leon Eisenberg, a former child psychiatrist, and a man of philosophy and science:
leon-eisenberg
Dr Eisenberg was then 89 years old and I wanted to convey how important his writings had been to me:mindlessness-and-brainlessness-in-psychiatry-1986
I did not expect a reply:
leon-eisenberg-to-peter-gordon-8-june-2016

A year later Leon Eisenberg died.

were-we-asleep-at-the-switch

After his death a memoir was discovered: which Eisenberg had named “Were We Asleep at the Switch?”.

Eisenberg suggested that a switch from ‘mind’ to ‘body’ has taken place in psychiatry as a discipline, which has led to overuse of medication.

He also argued that “monied interests” had been making de facto decisions on behalf of us all about the “science” of things that might affect us.

Eisenberg was worried that the overwhelming impact of economic considerations may have rendered, and might continue to render futile, the professional contributions of many brilliant, timely, and concerned working scientists.

leon-eisenberg-1987b

Dr Quackleben

Dr Quintin Quackleben was the doctor portrayed by Water Scott in ‘St Ronan’s Well’

Dr Quackleben must be very old now!

Yet, I do believe he is alive and well.

I once carved into one of our garden trees: “Nullius in verba” or “take nobody’s word for it”. There is guid reason why this was chosen as the motto of the Royal Society.

Peter is passionate about science. But science needs to be dispassionate: science is based upon a determination to be as “objective” as possible.

My worry is that Dr Quackleben, that sleekit, Leyden adorned physician, creeps into the life of us all.

My view is that it is vital that science, of any time or age, feels able to ask questions of Dr Quintin Quackleben.

Dr Quackleben from omphalos on Vimeo.

Closed by the Scottish Parliament: a Sunshine Act

PE1493 closed

My petition was closed on the 8th March 2016, after the following consideration by the Public Petition’s Committee:

PPC 8 March 2016

I was naturally disappointed.

I was invited by the Scottish Parliament to give feedback. This is what I said:

Thinking about the process that your petition went through, 
how fairly do you think your petition was dealt with?

Firstly I am impressed with how well organised and structured the PPC is. There are many petitions (a growing number?) and without the Clerks I cannot imagine that the committee members and Convener would manage to cope.

Secondly I am impressed that the PPC meetings are all recorded and archived both by Parliamentary TV and full verbatim Minutes. This is most commendable

My petition PE1493 was not fairly managed. The reasons are as follows:

(1) Apart from the initial opportunity to present my petition and engage directly with the committee there were no further opportunities to directly engage with the committee

(2) This lack of direct engagement deprives the public of consideration of the further evidence and correspondence collected by the PPC. Not once were any of the responses to PE1493 discussed publically in any detail by the PPC.

(3) Following my initial presentation of PE1493, all PPC meetings considering my petition were very short indeed. Many of them under a minute and the most common outcome was “the PPC will write to the Scottish Government”

(4) A huge amount of responsibility falls the way of the Senior Clerk and the Clerk’s team. Given this, and that this is a Committee for the public, who have elected the MSPs on the committee, it would seem important for the committee to acknowledge this. It would be helpful to set out clearly the qualifications and responsibilities of the Clerk and the line-management system, and system of appeal for any petitioner or member of public. Otherwise the PPC risks being considered undemocratic.

(5) As Petitioner for PE1493, in being asked to provide evidence from Scotland, to substantiate the request to consider legislation for healthcare workers and academics to declare financial conflicts of interest, I found myself in an impossible position. For example one piece of evidence, with full supporting material (film and the RCPsych approved power-point presentations of the academics) was refused publication by the PPC. In fact the PPC members, to my knowledge, never saw the letter. The decision not to publish was made by the Clerk based on Parliamentary Guidelines. I fully respect the right of the Scottish Parliament to determine what it publishes. However I feel very strongly that without this evidence (repeatedly asked for by the PPC, Scottish Government, and the Cabinet Minister for Health) that PE1493 could not be properly and meaningfully considered.

(6) PE1493 was closed. This was the deliberation of that decision of the PPC of 8th March 2016:

“There is stunned silence.”

Closure of my petition for a Sunshine Act for Scotland was then “minded” for closure by one of the members repeating what had been recorded by the Clerk in the papers for the meeting, that being:

“PE1493 by Peter John Gordon on a Sunshine Act for Scotland. To close the petition, under Rule 15.7, on the basis that the Scottish Government has committed to review the need for updated guidance on what the petition calls for and is consulting on the issue to gather views on what format it should take.”

My petition specifically asked for legislation because of the complete failure of previous guidance to be followed.

 

What did you hope to achieve by submitting your petition?

For a Sunshine Act to be introduced. For Scotland to lead the way in the UK.

To reduce harm caused by bias introduced into science by financial vested interests.

To address over-medicalisation and harmful misdirection of finite resources.

 

How do you feel about the outcomes?

Proud that I was brave enough and had sufficient stamina to pursue this petition.

Grateful that this Petition has encouraged wider discussion.

Disappointed at the skewed “Public Consultation” which deliberately chose not to explain to the consultees that existing Scottish Government Guidance has failed across our nation for more than 13 years. The information provided to the Consultees was drawn up by the Scottish Government.

Disappointed that PE1493 was closed without further opportunity to consider the evidence gathered and that it was closed based on the misunderstanding that PE1493 “called for updated guidance”

In conclusion:

The Scottish Parliament could have done more to hold the Scottish Government to account.

“Bipolarisation”

This is a BMJ response written by me on the 8th June 2011.

Four years on and I remain just as concerned about the 
over-medicalisation of "mood disorders". 

None of my words take away from my understanding of the suffering 
that disturbances of mood may bring.
A reply by Dr Peter Gordon to the Frontline article 
‘Bad Medicine: bipolar II disorder’ 
and the responses it attracted

“We can eventually make quite a lot of sense of this habitat if we patiently put together the data from different angles. But if we insist that our own window is the only one worth looking through, we shall not get very far.” Mary Midgley[1]

John Brockman in his collection of scientific essays ‘Beyond the scientific revolution: The Third Culture’[2] made two key demands for his book, that given the stormy debate raised by the recent Frontline article ‘Bad Medicine: bipolar II disorder’ [3] need to be considered:

(1) that we need to tolerate scientific disagreement,

(2) that the role of the academic includes communicating

Nevertheless, it was not helpful for Dr Spence to state that ‘Modern psychiatry, for all its evidence, is merely an intellectual construct, neither fact nor science.’ Reality is after all chock full of constructs, and here Dr Spence forgets many strides made in mental health care, however imperfect the classification of such suffering continue to be.[4] Here, Professor Michael Rutter suggests we remember: Progress in science—clinical science and basic science—has to come from questioning the given wisdom of the day and doing so in a style that builds constructively to a better understanding. In other words, destructive criticism is rarely the way to go[5]

It is understandable that Academic Psychiatry responded to Dr Spence most defensively; less understandable was all-out personal attack. Hackles raised may have weakened reason and here the academic world of British psychiatry, as Dr Spence argues, continues to ignore our professional oath primum non nocere (above all do no harm). Many of the respondents to Des Spence belong to the academically distinguished cohort who in July 2008 sounded the alarm for British psychiatry to ‘wake up.’ Their call somehow managed to present an approach to suffering that – going by the correspondence – raised more concern than it did support.[6]

Awoken from omphalos on Vimeo.

Rather than getting embroiled in the well-rehearsed arguments over the status of Bipolar II, I wish to focus on the underlying theme of Dr Spence’s frontline. He returns primarily to the medicalization of today (here 450 words can never be sufficient) and he has established, through a series of critiques that his concern is not confined to mental health.  Readers today realise that debate on medicalization is not new, and that the view presented by Ivan Illich in 1975 that this is universally bad is an over-simplistic approach.[7] [8]

Medicalisation-today

What follows in this brief paper is an examination of antidepressant prescribing and where it sits today within a world that is beyond that described by Ivan Illich. To consider such it is crucial to gather all available evidence-base, but also not to dismiss a collective narrative less quantifiable. Medicine, in its evidence-base, should accept that numbers (that which is quantifiable) and words (the qualitative) are equal forms of measurement. It is disappointing that we need reminding of this essential evidence and that the individual story is increasingly lost in pursuit of ever greater denominators.

Last year 40 million prescriptions of antidepressants were issued in England and 4.5 million in Scotland. This is, in its own right is an evidence base that Dr Spence insists must not be ignored and that Professor Ian Reid insists must not be superficially analysed.

If we divide the total number of prescriptions of antidepressants issued in England[9] (40 million) and Scotland[10] (4.5 million) last year, by an average of five prescriptions per depressed, we have a crude approximate of 9 million on regular pharmacological treatment.[11] Of course the true estimate will be considerably lower as revealed by Moore and colleagues,[12] as antidepressants are appropriately prescribed for other symptoms of life: in particular low dose Amitriptyline which is used in both sleep disorder and neuropathic pain.

In what follows, I will present 9 reasons, one per million, open of course to debate, why mankind should not simply dismiss the ‘cod philosophy’[13] of Dr Spence.

First: ‘truth.’

This small, but powerful word was used repeatedly by respondents in their opposing argument to Dr Des Spence.[14] Truth as it relates to evidence-based medicine is the subject of this edition of the British Medical Journal.

Dr Philip J Cowen, Professor of Psychopharmacology at the University of Oxford, light-heartedly questioned if Dr Des Spence was real: suggesting he might be no more than an editorial construct. Here Professor Cowen linked any ‘Big Pharma’ notion with fantastical conspiracy.[15] Yet printed in the same edition of that British Medical Journal was the alternative take on ‘truth’ as given by Ray Moynihan: “With medical science so contaminated by conflicts of interest, what evidence can we trust?”[16]

Professor Cowen’s response, entitled ‘Constructionism,’ mentioned one competing interest: “I am one of the authors of the “Shorter Oxford Textbook of Psychiatry” which treats bipolar II disorders as if it were a medical condition.”  In May 2011 Professor Cowen wrote the lead Editorial in the British Journal of Psychiatry – ‘Has psychopharmacology got a future? in which he revealed more conflicts of interest than he chose to reveal in his reply to Dr Spence.[17] In this editorial Cowen described past British Medical Journal coverage on antidepressants as ‘deranged’[18] and warned today of the demise of pharmaceutical innovation. It is true that in 2011 two major pharmaceutical companies have announced cessation of research activity in the field of psychiatric drug development. However not all involved in neuro-pharmaceutics seem as concerned as Professor Cowen, and indeed some within the industry believe that declining innovation is a myth.[19] Professor Cowen entitled his response to Dr Spence’s frontline ‘constructionism’; however his editorial in the British Journal of Psychiatry[20] made no mention of unpublished evidence, which leaves him, and the editors of the British Journal of Psychiatry, open to the charge of communicating less than the whole truth. Two of the most frequently cited cases involving unpublished evidence relate to antidepressants: paroxetine and reboxetine. In the case of the latter, it was revealed recently that 74% of patient data had previously been unpublished: when this evidence was included the conclusion was rather different than that so marketed: “reboxetine is overall an ineffective and potentially harmful antidepressant”[21]

fair to conclude

In 2008, Dr Ben Goldacre published ‘Bad Science’[22] and it has since become a bestseller. Two chapters in this book are worth considering when it comes to debate on antidepressant prescribing. The first is ‘How the media promote the public misunderstanding of science.’ We are used to journalism that reduces the horrid reality of depressive illness: for example calling medication ‘happy pills’ or sufferers ‘pill poppers.’ Yet the chapter that follows is equally important, as in it Ben Goldacre suggests reasons “why clever people believe stupid things.”  In terms of evidence-based research he argues that we: ‘tend to seek out confirmatory information on any given hypothesis. ‘[23]

Dr Richard Smith, former Editor of the British Medical Journal departed office in 2003 with his own concern:  In his ‘goodbye’, Dr Smith warned of confounding marketing with medical education. This is not a new phenomenon, but in our generation cannot be dismissed, despite the good that many drugs have brought to life and greater longevity. In terms of Academic Psychiatry this subject was given careful consideration by Thomas A. Ban.[25]

Medical 203 from omphalos on Vimeo.

Second: what is health?
The central tenet of Des Spence’s argument is that too much of life is being ‘disordered’ and that this has consequences for us all. Some of the psychiatrists who responded to his frontline piece, accused him of either mind-body dualism or worse still ‘trivialising’ suffering. Anybody who has read the British Medical Journal[26], or any other journal for that matter over the last few years, cannot have failed to notice that boundaries of illness are moving: today we have pre-hypertension, cholesterolaemia, glycaemia etc.

25

As an old-age psychiatrist, I am obviously interested in research into Alzheimer’s pathology.[27] It appears to be emerging that this disease is not an ‘all-or-none’ entity: amyloids, neurofibrillary tangles and apoE alleles, are all now thought to be active components of normal neuroplastic processes. In other words, Alzheimer’s is not a disease (as so classically understood) but a physiological yet detrimental response to complex neuroplasticities. Ming Yi, from the Neuroscience Research Institute, Peking University, in consideration of this new understanding of Alzheimer’s pathology, suggests that we define health first, then diseases. Such a strategy will, Ming Yi so argues, reveal the ‘truth’ that most diseases appear in a dormant manner originating from a physiological continuum. Furthermore, Yi argues that this understanding not only provides a consensual framework for researchers, but should also benefit early diagnosis and intervention for patients. He goes on to suggest that such a ‘healthy’ framework might be a parallel to follow for mood disorders and their treatment.

Third: ticking all the boxes
In his reply to the frontline, Dr Ian M. Anderson, psychiatrist, questioned if we have become over-reliant on self-report measures such as questionnaires.[28] We must not forget that we are living in an age of patient empowerment. This is most welcome but depends crucially upon coherent public health education. Under the quality and outcomes framework, UK general practitioners are rewarded for using validated questionnaire measures of the severity of depression at the outset of treatment. While general practitioners are using the questionnaires in more than 90% of diagnosed cases, qualitative evidence suggests they doubt the validity of the measures and use their clinical judgment to decide about treatment regardless of patients’ questionnaire scores.[29] Professors Kendrick and Dowrick, in the only large scale study on the use of such self-report questionnaires concluded: “It should be emphasised that neither PHQ- 9 and HAD-D is an optimum measure of the severity of depression, and scores above the recommended cut-off values give only an indication that a particular patient is likely to have major depressive disorder.”

‘Incentivised care’, such as this, Chris van Weel, professor of general practice has argued is no substitute for professional judgment: “given the limited research, this is an area where general practitioners’ experience is well ahead of scientific evidence. Exploration of this experience could further improve the QOF process.”[30] In Scotland, the NHS supported campaign ‘doingwell’ launched itself upon the back of internet self-assessment by PHQ-9. Beyond Professor Van Weel, concern has been expressed more widely, including Professor Ian Reid of Aberdeen: “it maybe that QOF depression measures will simply have to be reconsidered if we wish to keep faith with the evidence base. For now, GPs should continue to exercise circumspection when interpreting depression severity measure scores.”[31]

qof2

Fourth: all that is classified.
As someone who is interested in the history of psychiatry there is one perennial conundrum that has presented itself every year since Johann Reil coined psychiatry[32]: the classification of mental suffering. Dr Spence has every right to remind us that we have not yet cracked this. Today it is necessary to follow Professor Craddock’s call for pragmatism. The search for biological markers will go on, and it is a cause that we should support, however there are many today who argue that whilst this is necessary for understanding it is not sufficient.[33] Today adding to a list for potential frames for classification are the adaptionists such as Randolph Nesse and his Evolutionary Medicine. In this subject it is helpful to read the range of intellectual arguments presented in the essays collected by John Brockman.[34]

In defending the construct of ‘Bipolar II disorder’ several correspondents returned to ICD and DSM classifications as if they were as determined as our genetic code. Here it is worth reporting what Dr Allen Frances, said in a recent interview about the delay in formulating DSM 5:  “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”[35] Dr Frances was the doctor who spear-headed the formulation of the previous version of DSM.

Fifth: necessary but not sufficient.
Evidence base is absolutely necessary for progressing our understanding but many of today’s intellectuals would argue that it is not sufficient. In addition we need intelligent kindness and to embrace the notion of hole ousia, relationships, real world, and the wisdom of the Scotttish physicist James Clerk Maxwell. Or as Edwin Morgan the poet put it: “holding hands amongst the atoms.”

With technological advance, it is understandable why mankind has chosen to view life through the paradigm of illness, when actually what we seek is health. Wholesome humanity must not today approach this back to front, or the result will bring harm.

One respondent suggested: “Dr Spence is right when he suggests that the diagnosis of bipolar II disorder is a real clinical issue. However, an over-diagnosis, whenever possible, doesn’t seem to carry the same negative consequences as an under-diagnosis.”[36] However, it is essential that we do consider the potential harm of over-diagnosis,[37] [38] [39] especially when the USA, our mental weather vane, statistically reveals that the incidence of major depression doubled in a decade from 1992 to 2002.[40]

redefine1

Sixth: stigma and the Hydra.
Every window views stigma differently. Education here is important, but surely such is not just for patients, but for us all? Stigma grow heads like the Hydra-monster, and it is not the simple case that giving a ‘diagnosis’ reduces stigma. Research in its beginning supports my ‘feeling’ that such is fallacy.[41]

Window Tax from omphalos on Vimeo.

Seventh: primum non nocere
Dr D.J Smith et al claim that up to 21% of primary care patients with depression in fact have unrecognised bipolar disorder, and the authors advise against inappropriate treatment by antidepressants in this significant minority as ‘antidepressants may trigger agitated, mixed or manic mood states.’[42] Other academics have replied stating that this research supports treatment for Bipolar II patients with atypical anti-psychotics such as Quetiapine and the anticonvulsant Lamotrigine.[43]. Such drugs, when appropriately used can reduce suffering, but equally we must consider the side-effects, and realisations of harm that only may appear many years later.[44]

poll

Eighth: Continuing medical education
Professor Nick Craddock, speaking for the 36 academics who asked our profession to ‘wake up’ reaffirmed a collective view: “we are not terribly interested in what is past.”[45]

The Royal College of Psychiatry has embraced the modern, multi-media techniques with its CME modules and podcasts, however look at the content. There is no history, except that of ancient lunacy laws. Where are the considerations of the changing classifications of mental illness, the social and cultural context of mental illness, philosophy[46], the language of science and indeed any ideological considerations beyond the medical model: holism, reductionism, ethics, philosophy, narrative medicine? They just are not there.

1a

Nine million prescribed:
As a citizen of Scotland who was started on an antidepressant during the 1990’s Defeat Depression Campaign, I shall conclude this piece by giving contrasting representations of this campaign as understood by a Professor in tertiary referrals and that of a doctor on the frontline:

Let us start with the former, Professor Reid of Aberdeen stated in one of his replies to Dr Spence: “the Defeat Depression Campaign went some way to improving antidepressant practice, by increasing the dose and duration of antidepressant prescription. This is what resulted in the much misunderstood increase in antidepressant prescriptions: not more people getting antidepressants, but those receiving them getting them – entirely within guideline recommendations.” With the dearth of long-term studies it is hard to see what evidence base the Defeat Depression Campaign based its recommended duration of treatment. Even today, recommended duration of treatment is still far from clear, and there is little clarity about withdrawing treatment.[47]

Professor Reid makes a further most important point: “Simply stating numbers of prescriptions, turns out not to be very informative, but entirely misleading. Indeed, this approach led the Scottish media (and the Government’s Information and Statistics Division) to over-estimate the proportion of the population taking antidepressants by a factor of 5.”  Professor Reid then goes on to state that “the quality of care has improved, and even suicide rates may have dropped as a consequence (of the Defeat Depression Campaign)” However, Melissa Raven and Jon Jureidini presented both epidemiological and philosophical argument why we cannot yet be certain that antidepressants have reduced suicide rates. [48]

In contrast, Dr Spence’s experience of the Defeat Depression Campaign: “you will note the large rises in depression diagnosis in the young, rising quickly in the mid nineties, sustained for 7 years and then declining rapidly in 2003. I worked through out this period and anecdotally will tell you what happened. We were berated for under-diagnosing depression and so treated patients. After 5-6 years it was patently obvious that this wasn’t the case and we were over prescribing medication. We lost faith. We had simply medicalised normal reactive behaviour and denied young patients the opportunity to develop coping skills. This is what happened, I was there.”

The truth of this prescriber’s experience is another which should not be ignored. This author has never had bipolar disorder but has suffered from depression and has been on paroxetine since the ‘Depeat Depression Campaign’:

Gilbert Farie revisited from omphalos on Vimeo.

Dr Spence, reminds us that proportionality of understanding comes in words as well as numbers:, “The number of antidepressants prescribed by the NHS in the United Kingdom almost doubled during one decade. There is no evidence that our mental health has improved over this time and plenty to say it hasn’t. I do not celebrate the ever increasing consumption of antidepressants but mourn the poverty of our thinking.” This has been shown to be an argument we do not wish to hear; however it is essential that the humanities (given its classical name) must not be eliminated, and that biological research should never ignore the world we live in. Otherwise the stand-alone brain will fool us all.[49]

Conclusion: windows
It is our very need to ease suffering that brings great passion to debate. This is uniquely human, and a dimension that must never be reduced. Understanding requires that we must see the real world through more than our own window: today’s mental biologism is not enough – it is necessary but not sufficient. Equally quantitative evidence base is necessary but requires qualitative understanding. Here Professor Greenhalgh reminds us that medicine needs narrative more than we like to believe.[50] 

 


[1] Midgley, Mary. Notes. 2003, pp. 26-27.

[2] Brockman, John. Beyond the scientific revolution: The Third Culture. 1st Touchstone Ed edition. May 1996

[3] Spence, Des. Bad Medicine: bipolar II disorder. Frontline article. British Medical Journal. 4th May 2011. 342:d2767

[4] Ilangaratne, Jay. BMJ rapid-response. Condemning Psychiatry, Ideas Based Medicine, and Leading Questions Published 11th May 2011

[5] Rutter, Michael. Challenging psychiatry. Interviewed by Mathew Billingsley. BMJ Careers. 9th February 2011

[6] Craddock, Nick et al. Wake-up call for British psychiatry. The British Journal of Psychiatry, Jul 2008; 193: 6 – 9.

[7] Illich, Ivan Medical Nemesis. 1975

[8] Gordon, Peter J. Gilbert Farie Revisited. A reply to Reply to the Editorial: Has psychopharmacology got a future? May 2011. The British Journal of Psychiatry chose not to publish this.

[9] Population of England in 2010 approximately 51.5 million. Office for National statistics

[10] Population of Scotland in 2010 approximately 5.2 million. General Register Office of Scotland

[11] Hickey, Finlay. Lead Pharmacist Mid Highland CHP.  Kindly provided prescribing data on antidepressants for Scotland over the past 5 years.

[12] Moore, Michael, Kendrick, Tony et al. Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database. British Medical Journal. 15 October 2009. 10.1136/bmj.b3999

[13] Reid, Ian. BMJ Rapid response.  Practical considerations. Published 26 May 2011

[14] Reid, Ian.  BMJ Rapid response. Truth, not Beauty. Published 27 May 2011

[15] Cowen, Philip. BMJ Rapid response. Constructionism. Published 10 may 2011.”Indeed for some time the ontological status of Spence himself has been contested as a possible BMJ construct: a frontline, not to say “full time”, no nonsense, hard-headed, GP whose very appellation (Dispense) underlines the pervasive reach of big Pharma.”

[16] Moynihan, Ray. Reality Check: It’s time to rebuild the evidence base. British Medical Journal. 2011;342:doi:10.1136/bmj.d3004 (Published 25 May 2011)

[17] Cowen, Philip. Has psychopharmacology got a future?’ British Journal of Psychiatry. 198: 333-335. (Published May 2011)

[18] Cowen, Philip. Has psychopharmacology got a future?’ British Journal of Psychiatry. 198: 333-335. (Published May 2011)

[19] Schmid, Dennis & Schmid, Esther. Keynote review: Is declining innovation in the pharmaceutical industry a myth? DDT, Volume 10, Number 15 (published August 2005) “If you say something often enough, it must be true. Everyone knows that innovation is declining and is the source of all the woes of the pharmaceutical industry. But who has checked the facts?  The myth of the innovation deficit is exactly that – a myth”

[20] Cowen, Philip. Has psychopharmacology got a future?’ British Journal of Psychiatry. 198: 333-335. (Published May 2011)

[21] Wieseler, Beate et al. Finding studies on reboxetine: a tale of hide and seek. British Medical Journal 2010;341:doi:10.1136/bmj.c4942 (Published 12 October 2010)

[22] Goldacre, Ben. Bad Science. Fourth Estate (Oct 2008)

[23] Tallis, Raymond. Aping Mankind: Neuromania, Darwinitis and the misrepresentation of humanity. Acumen (published June 2011)

[24] Smith, Richard. Editorial: Medical journals and pharmaceutical companies: uneasy bedfellows British Medical Journal. 326 : 1202 (Published 29 May 2003)

[25] Ban, Thomas. Academic psychiatry and the pharmaceutical industry Progress. Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 429 – 441

[26] Godlee, Fiona. Who should define disease? British Medical Journal;342:doi:10.1136/bmj.d2974. Published 11 May 2011)

[27] Yi, Ming. BMJ Rapid response. Shall we define health first, then diseases? Neuroscience Research Institute, Peking. Published 13 May 2011

[28] Anderson, Ian. BMJ Rapid response: Bad medicine or bad mouthing? British Medical Journal. Published 10 May 2011: “Bipolar II disorder’s current celebrity fashion status feeds into this. But once again this is not confined to psychiatry, and every doctor has to deal with unexplained medical and psychological symptoms. The increasing “tick box” approach to medicine, at the expense of clinical judgement, can only weaken our ability to make a full assessment; this usually needs to incorporate third party information.”

[29] Dowrick, Christopher et al. Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. British Medical Journal. 338:b750 (Published 19 March 2009)

[30] Van Weel, Chris. Incentivised care is no substitute for professional judgment. British Medical Journal. 338:b934 (Published 19 March 2009)

[31] Reid, Ian & Cameron, Isobel. BMJ Rapid response: Depression severity measurement in primary care. Printed 11 April 2009

[32] Marneros, Andreas. Psychiatry’s 200th birthday. British Journal of Psychiatry. 10.1192/bjp.bp.108.051367 February 2008

[33] Tallis, Raymond. The Hand: A philosophical inquiry into
human being
(2003) I Am: A Philosophical Inquiry into First-Person Being (2004) The Knowing Animal: A Philosophical Inquiry into Knowledge and Truth (2005) Edinburgh University Press

[34] Brockman, John. Beyond the scientific revolution: The Third Culture. 1st Touchstone Ed edition. May 1996

[35] Greenberg, Gary. Inside the battle to define mental illness. Wired magazine. January 2011

[36] Sani, Gabriele et al. BMJ Rapid response: Bipolar II disorder: bad medicine or bad criticism? Published 31 May 2011

[37] Irwin, Charles et al. America’s adolescents: where have we been, where are we going? Journal of Adolescent Health, Volume 31, Issue 6, Supplement 1, December 2002, Pages 91-121

[38] Robin, A et al. Over-diagnosis and breast cancer screening. European Journal of Cancer Supplements, Volume 4, Issue 2, March 2006, Pages 6-9.

[39] Stephen Jones, J. Prostate Cancer: Are We Over-Diagnosing—or Under-Thinking? 

European Urology, Volume 53, Issue 1, January 2008, Pages 10-12

[40]   Compton, W. M et al. Changes in the prevalence of major depression and co-morbid substance use disorders in the United States between 1991-1992 and 2001-2002. American Journal of Psychiatry. 163(12):2141-7. Published December 2006

[41] B Rüscha, Nicolas et al. Biogenetic models of psychopathology, implicit guilt and mental illness stigma. Psychiatry Research 179 (May 2010)  328-323

[42] Smith, D. J. et al. Unrecognised bipolar disorder in primary care patients with depression. British Journal of Psychiatry. 10.1192/bjp.bp.110.083840. Published 3 February 2011

[43] Ferrier, Nicol et al. BMJ Rapid response: Bad medicine or bad practice. British Medical Journal. Published 12 May 2011

[44] Committee of Safety of Medicine. March 2004. In March 2004, the UK Committee of Safety of Medicines (CSM) informed clinicians that risperidone and olanzapine should not be used to treat behavioural and psychological symptoms of dementia (BPSD) because of increased risk of strokes with both drugs and increased risk of mortality with olanzapine.

[45] Craddock, Nick et al. Wake up call: Response from authors. Published 19 Oct 2008

[46] Nagel, Thomas. The view from nowhere.“Philosophy is the childhood of the intellect, and a culture that tries to skip it will never grow up.” Published 1989. OxfordUniversity Press

[47] Burton et al. Newly initiated antidepressant treatment in Scotland. Evidence into Practice. 2010

[48] Isacsson, Göran, & Rich, Charles (For) Jureidini, Jon & Raven, Melissa (Against). IN DEBATE: The increased use of antidepressants has contributed to the worldwide reduction in suicide The British Journal of Psychiatry (2010) 196: 429-433.

[49] Tallis, Raymond. Aping Mankind: Neuromania, Darwinitis and the misrepresentation of humanity. Acumen (published June 2011)

[50] Greenhalgh, Trisha. Soft Rebuttal. Rapid Response British Medical Journal. 31st Dec 2004.

Tony Delamothe: ‘The “truth,” if and when it emerges, will be thanks to the positivist philosophy that underpins quantitative research.’

Trisha Greenhalgh: Is this a declaration of Tony Delamothe’s personal bias or an indication of the BMJ’s editorial position? If the latter, I challenge the BMJ’s Editor to make a formal statement to the effect that:

“Qualitative research is considered by the BMJ to be inherently lower quality than quantitative research. Authors seeking to publish qualitative research should doff their caps accordingly and strive to ensure that their submissions are philosophically nihilist, atheoretical and present a single, unambiguous truth with narrow confidence intervals. Co-authorship with professors of epidemiology will substantially increase the chances of acceptance of qualitative papers.”

 

What you need to know

1 in 7 Scots are on an antidepressant. Some Scottish academics have argued that this is “appropriate prescribing” for “recurrent” and “chronic” conditions.

Antipsychotic prescribing, in all age-groups, has risen year-on-year since the Scottish Government started measuring such prescribing. Last week NHS Scotland was struggling to source one such antipsychotic, namely haloperidol. Intramuscular haloperidol may not be available for 14 months. I do not know if this is a supply or demand issue, however this medication is being most extensively used in NHS hospitals in Scotland despite generally being prescribed “off-label”.

With this in mind I present a pattern that emerged from reading the current British Medical Journal alongside my weekend newspapers.  Here is what they both suggested that “you need to know”:

All the other children are on it, 21 Nov 2015, Guardian Andrew Lansley, Roche 20 Nov 2013 Disney and McDonald's staple, 21 Nov 2015, Guardian Generation meds, 21 Nov 2015, Guardian Long term effects on oor children, Guardian, 21 Nov 2015 Now you are my friend, Nov 21, 2015, Guardian Pharmacological mission creep, BMJ, 20 Nov 2015 What you need to know, Bmj, 21 Nov 2015

Update, 5th October 2016. The following was published on the 
front page of the Scotsman newspaper: 

"Mental health prescriptions hit ten-year high"

prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-a prescriptions-for-mental-health-drugs-10-year-high-nhs-scotland-2016-b

The figures are from the Scottish Government and can be accessed here.

Lurasidone – “Special Article”

I noticed this “Special Article” published in the October edition of the British Journal of Psychiatry. It details a novel antipsychotic medication called Lurasidone  (trade name Latuda):

Lurasidone, Oct 2015

I would anticipate that this is the start of a programme to educate psychiatrists in the UK on this new drug.

I note from the ProPublica Searchable database that one of the authors of this “Special Article” has received payments from the drug’s manufacturers as below:

Leslie Citrome