This letter written by Peter and Sian has just been published in the BMJ
(dated 20 September 2017):
This letter written by Peter and Sian has just been published in the BMJ
This letter written by Peter and Sian has just been published in the BMJ
(dated 20 September 2017):
Crowd-funding is nothing new. The Martyrs’ monument was funded by public subscriptions to redress the events of 50 years previously when five Scots were transported for sedition. Their speaking up for the common people was judged by those in authority to be “wicked and felonious”.
The Foundation stone for the Martyrs’ Monument was laid on the 21st August 1844:
400 people attended the laying of the foundation stone. 183 years to the day later it happened to be five of us who gathered for a peaceful protest recognising the ongoing imbalance in power between those in high office and those in the general population.
Walter Humes, writing in Scottish Review, 21st September 2015:
President Obama put this in a slightly different way:
Our protest also happened to coincide with a solar eclipse. My particular experience with high office has related to my petition for a Sunshine Act for Scotland:
“you are either abstinent or promiscuous when it comes to industry. Well you can see which side I am on”.
“For those of you who watch Panorama, I do not give my consent for you to film this”
“Who would have thought that Pharma Hospitality could cause excessive weight gain and type II diabetes? They kept that quiet”, I replied, ruefully patting my stomach.”
“this latest non-problem”
“it is time we all grew up”
This week the International Congress for the Royal College of Psychiatrists is taking place in Edinburgh. It is titled “Psychiatry without Borders”.
Given my concerns about the harms associated with over-medicalisation I decided to make a peaceful protest outside.
I was born in Edinburgh in 1967.
This was a home-made protest.
I have no associations with Critical Psychiatry, Anti-Psychiatry, Scientologists, the Citizens Commission on Human Rights.
I am simply a doctor who is interested in ethics.
I am of the view that critical thinking is an essential part of science.
I understand that biases come in all forms. However there is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.
Thank you to all who came to talk to me on the day. Particular thanks to Chrys Muirhead and her son Daniel for all their support
I waited the full day as I wanted to meet the Cabinet Minister for Health (Scottish Government) outside the International Congress. This was my experience:
The public consultation can be found here.
I wrote “Transparency at the Top: British Psychiatry” in April 2015 but did not share it publically as I wanted to give the Royal College of Psychiatrists time to improve the governance of financial conflicts of interest. Over the last 2 years improvements have been made by the Royal College of Psychiatrists however the system in place is unsearchable, costly, and bureaucratic. It also does not help determine how much of the £340 million that the pharmaceutical industry pays each year for “promotional activities” goes to the “top” educators (key opinion leaders) in UK psychiatry.
Sir Professor Simon Wessely has been an outstanding President and has carefully listened to the concerns that I have kept raising on this issue. This week he hands over the Presidency of the Royal College of Psychiatrists to Wendy Burn.
Tomorrow, the International Congress: Psychiatry without Borders begins in Edinburgh. I will be protesting outside because I remain concerned about the considerable reach (to the many) of a handful of educators: “The Law of the Few”.
Here follows my original transcript, dated 25 April 2015:
The Chief Executive of the GMC recently confirmed in the BMJ:
To ensure public transparency of financial payments to healthcare workers and academics both France and America have introduced a Sunshine Act. In the UK we do not have such statutory basis to transparency. Royal colleges rely on Guidance such as this guidance, CR148, by the Royal College of Psychiatrists*:
The Royal College of Psychiatrists Guidance, like The GMC, gives clear and unambiguous guidance*:
The Royal College of Psychiatrists has recently expressed that, in addition to such clear and unambiguous College guidance (CR148), that the Association of the British Pharmaceutical Industry (ABPI) “central platform” to be introduced in 2016, will ensure transparency that will “so avoid some of the criticisms of yesteryear”:
The ABPI “Central Register” has no statutory underpinning and any healthcare worker or academic can choose to opt out of revealing any financial payments made from industry.
It is perhaps then an opportune time to consider whether the Royal College of Psychiatrists is correct to express confidence that we may be able to “avoid some of the criticisms of yesteryear” in regards to transparency in regards to the relationship between industry and psychiatrists. To consider this, we might do well to look at some of the key College leads. So to start at the top this should include the current President of the Royal College of Psychiatrists. Such a consideration should also include the current Chair of the College Psychopharmacology Committee. To be properly representative of College leads, this consideration should also include a Psychiatrist who is today widely considered as a ‘key opinion leader’ in British psychiatry.
The only purpose of this consideration is to attempt to examine if our College leads are exemplars in transparency and to attempt to establish if they have followed College guidance CR148.
Sir Professor Simon Wessely was elected last year as President of the Royal College of Psychiatrists and took presidential office on the 26th June 2014. The week after his appointment, Professor Wessely was interviewed on BBC Radio 4 and, as part of this public broadcast, was part of a discussion with James Davies, University of Oxford:
This is an emphatic statement made publicly by the President of the Royal College of Psychiatrists.
In fact Wessely has been transparent about “Financial Disclosures” as given here following a co-authored review paper published in JAMA in 2014: “Dr Wessely has received financial support from Pierre Fabry Pharmaceuticals and from Eli Lilly and Co to attend academic meetings and for Speaking engagements.”
This full transparency helped Joel Kauffman consider the 2004 JAMA Editorial and this can be read in full here. But meantime, here is the relevant extract:
Those at the top of British psychiatry would appear to have a range of definitions of “transparency”? It is certainly very clear that Sir Professor Wessely does not have anywhere like the volume of working relationships with industry as some of the other current College leads. Last year Wessely gave the keynote lecture “Psychiatry under fire” at the following conference. This was not a sponsored talk as the programme makes clear. The Conference was organised by Professor Allan Young who confirms that the “objective” of this symposium is to provide “independent” education to help “achieve personal CPD objectives and in your everyday clinical practice”.
Professor Allan Young is also Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists and his declarations are publicly available here where he confirms that he is paid for “lectures and Advisory Boards for all major pharmaceutical companies with drugs used in affective and related disorders”. Professor Allan Young may well be one of the most influential ‘key opinion leaders’ in British psychiatry. In this role, as a most influential educator Professor Allan Young has recently been considered here and here.
Also giving a talk at this 2014 “Latest Advances in Psychiatry Symposium” is Professor Guy Goodwin who is also considered to be a “key opinion leader” and who is undoubtedly one of those at the “top” of the hierarchy of British Psychiatry.
Professor Guy Goodwin featured centrally on the BBC Panorama programme in the following month. This programme was titled “who is paying your doctor” and Dr Goodwin came under considerable scrutiny. However it should be the case, that such scrutiny should include not just a single, individual “key opinion leader” but those like the Chair of Psychopharmacology Committee and the President of the Royal College of Psychiatrists. For patients to have trust in the medical profession it should be the case that such leads are exemplars when it comes to transparency of financial interests.
Following the Panorama programme in which Professor Guy Goodwin featured, the Head of Professor Goodwin’s University Department, had an article published in the BMJ where he expressed the view that the media harm caused by raising the subject of transparency “may outweigh any good”. An alternative view is given here. As a result, Dr David Healy, Director of the North Wales Department of Psychological Medicine offered a proposal to ensure wider consideration of transparency in British Psychiatry. This proposal for a “proper and open debate” was copied to a wide range of individuals including Professor Goodwin and had previously been discussed with Sir Simon Wessely. The correspondence can be read here .
As President of the Royal College of Psychiatrists, it is clear that speaking proportionally, most of the research Professor Wessely has been involved in has not involved working with the pharmaceutical Industry. Wessely is after all a professor of psychological medicine at the Institute of Psychiatry, King’s College London and head of its department of psychological medicine. Compared to some of the psychiatrist colleagues around him, and in particular “key opinion leaders” it is no doubt the case that Wessely has worked less with industry. However, it is not the case that he has “never worked with industry” as he emphatically stated on Radio just after becoming President of the Royal College of Psychiatrists.
In the past, Professor Wessely has helped prepare review articles through “educational grants” from the pharmaceutical industry. It perhaps may be argued that this is not “working” with industry. Though College guidance CR148 does seem to be much clearer in what it expects in terms of transparency. This was one such article involving Wessely and another one can be accessed here.
A few years before College Guidance CR148 was introduced, and long before Wessely was elected President of the Royal College of Psychiatrists, he gave his personal view on ‘working’ relationships with industry and insisted that it was “time we doctors grew up”. At the time, the BMJ published a range of views, and one of these has been included alongside Wessely’s to demonstrate this range. Professor Wessely’s personal view is now over a decade old and it would be helpful to know if his views have changed over this period of time.
Is it the case that calling for transparency regarding financial payments may cause more harm than good? Some of those at the top of British psychiatry would appear to have put forward this view, arguing that such will damage public trust. Yet the GMC are clear what they expect of their professional group, namely doctors. Is it not time that we had an open public debate about this involving more than those just at the top?
*Since writing this CR148 was replaced in March 2017 by CR202
Update of 11 June 2017: "The Law of the Few"
This week, UK medical professionals were alerted of the permanent discontinuation of the supply of MODECATE (fluphenazine decanoate) injection by the end of 2018:
In October 2014, UK medical professionals were informed of permanent discontinuation of PIPORTIL Depot (pipothiazine palmitate):
Advice is given with these notifications of alternative depot medications. In changing patients from one depot to another I have found that there can be severe deterioration in mental health and that this can endure far beyond the transition phase.
My concern is that patients may be started on long-term medication without realising (being informed) that the medication they are taking may not be available at a future time and that this may have consequences for them. We must also consider that depot antipsychotics can be given without consent if certain criteria of mental health legislation are met.
Malcolm Gladwell in his book ‘The Tipping Point’ describes what he terms “The Law of the Few”: namely that the influence of a few people can result in change in behaviour across a wider population.
This Hole Ousia post is about the education of psychiatrists and takes all its material from publically available sources. This post hopes to demonstrate the considerable reach (to the many) of a handful of educators.
This post follows on from the evidence that was gathered for my petition to the Scottish Parliament to consider introducing a Sunshine Act for Scotland. That petition closed 16 months ago following a consultation with the Scottish public who, in majority, asked that payments made to healthcare workers and academics be declared on a mandatory basis. I have argued the reasons why I am of the view that such mandatory declarations should be registered on a single, open, central, searchable, independent database.
Evidence has demonstrated that when a doctor has a financial “conflict of interest”, this can affect the treatment decisions they make, or recommend. There is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.
The post has come about following my invitations in the last month to Continuing Medical Education (CME) provided in my place of employment (NHS Scotland). I do not knowingly attend sponsored medical education and so declined these two talks. The first was by Dr Peter Haddad (sponsored by Lundbeck) and the next one, just two weeks later, was by Professor McAllister Williams (sponsored by Lundbeck).
I am an ordinary psychiatrist working in a provincial NHS general hospital and to find such prominent individuals visiting our wee corner of Scotland left me to reflect upon the wide influence of a few key individuals.
The British Association for Psychopharmacology (BAP) describes itself as “a learned society and registered charity. It promotes research and education in Psychopharmacology and related areas, and brings together people in academia, health services, and industry.”
Professor Hamish McAllister-Williams is an Ex-Officio Member of BAP and is currently the BAP Director of Education. Dr Peter Haddad, former Honorary General Secretary of BAP, has been involved over a number of years with BAP education providing articles and masterclasses.
Over the course of my career as a psychiatrist I have frequently heard colleagues say that BAP “is the place to go” for CME. It is now a requirement for General Medical Council Appraisal and Revalidation to demonstrate with our College that we have participated in CME. Once this has been demonstrated the Royal College of Psychiatrists will issue a Certificate of “Good medical standing”.
As BAP Director of Education, Professor McAllister Williams recently shared this offer to trainee psychiatrists. Following the dissemination of this I took the opportunity to look more closely at the current BAP calendar for Continuing Medical Education. This again demonstrates the wide influence of a small number of individuals, some of whom would appear (within the limits of the current voluntary disclosure regime) to have potential financial conflicts of interest.
In the remaining part of this post I have included a few examples
As BAP Director of Education, Professor McAllister Williams chaired this BAP 2015 Summer Meeting: “Expert Seminar in Psychopharmacology”. The key-note speaker was Professor Stephen Stahl who many consider as one of the most influential key opinion leaders in world psychiatry.
In the USA, pharmaceutical and medical device companies are required by law to release details of their payments to doctors and teaching hospitals for promotional talks, research and consulting. This was the return for Professor Stahl at the time of his contribution to BAP as an educator of UK psychiatrists:
In the UK disclosure of payments is on a voluntary basis.
Professor David Nutt, former BAP President, has declared financial interests on the voluntary ABPI Register. Over the ABPI “disclosure period”, Professor Nutt has declared just short of £46,000 that he has received from Janssen-Cilag Ltd and Lundbeck Ltd.
There are strong links between BAP and the Royal College of Psychiatrists. The President Elect for BAP is Professor Allan Young. Professor Allan Young is Chair of the Psychopharmacology Committee of the Royal College of Psychiatrists. Dr McAllister Williams, the BAP Director of Education is an appointed member of this Committee. Some years ago I wrote this post about the Royal College of Psychiatrists Psychopharmacology Committee.
Some years ago I put together this Hole Ousia post on Professor Allan Young and also this post. It is clear that Professor Allan Young remains a very active educator and opinion leader in the UK and beyond:
Professor Guy Goodwin was President of BAP between 2004 and 2005. In April 2014 he featured prominently on BBC Panorama:
On the 40th anniversary of BAP, Professor Peter J Cowen was given the Lifetime Achievement award:
The recently retired CEO of the Royal College of Psychiatrists, Vanessa Cameron, who had been with the College for 36 years was interviewed for the Psychiatric Bulletin in December 2016. This was the view that she expressed:
Each time I reconsider this subject I do not find evidence to support this view. My worry is that the Royal College of Psychiatrists is being complacent in facilitating the education of the many by such a small group of individuals. The Law of the Few.
Footnote: If you click on each invite below you will access what is available in the public domain regarding the educational activities of the recent speakers. I apologise if this is in any way an incomplete record.
To be revalidated by the General Medical Council all UK doctors have to evidence participation in Continuing Medical Education (CME). This is based upon an accredited system of Continuing Professional Development (CPD).
CPD is mandatory.
This Hole Ousia post considers CPD for UK psychiatrists.
This week I was included in a circular e-mail that ‘sign-posted’ this free CPD educational opportunity for trainee psychiatrists. I was asked to share this with trainees.
BAP is acronym for the British Association of Psychopharmacology. I frequently hear colleagues describe it as “the place to go to” for CPD.
This is the current Calendar:
I have written on a number of occasions over the last few years to BAP about transparency of financial conflicts of interest:
BAP have now significantly improved on transparency and each speaker now has a link to any declared financial interests. This is available to professionals and public alike.
The declarations however give no details of amounts paid for any particular service.
BAP educational events are regularly advertised in the British Journal of Psychiatry
The Chief Executive of the Royal College of Psychiatrists recently offered this reassurance (Psychiatric Bulletin, December 2016):
Last year £340 million was paid by the Pharmaceutical Industry to UK healthcare workers for “promotional activities”.
There is currently a voluntary register (ABPI).
The BMJ reported this in March 2017:
As it stands, professionals, patients and public alike can have no clear understanding of where this £340 million went to in the UK for “promotional activities”.
However we do have evidence that promotional activity can lead to doctors recommending worse treatments for patients.
Returning to the Continuing Professional Development (CPD) calendar that the British Association of Psychopharmacology (BAP) is currently providing. It took me a full day to go through the declarations. These follow below, in alphabetical order of educator:
In summary it is encouraging to see these declarations of financial interests for BAP educators. This is a group of professionals who have a position of significant influence over the prescribing patterns of current and future psychiatrists. This means that even those doctors who regard themselves as not being subject to conflicts of interest may be indirectly influenced.
It is my concern that this potential influence is not always recognised by colleagues attending CPD in good faith and this is my reason for compiling this post.
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”.  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”. 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.  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”.  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.  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 86 “National 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.