Credible or incredible: experience is evidence

A senior Scottish figure once gave me advice that it is very important to be perceived as “credible”.

I was thinking about this advice recently when the convener of the Parliamentary Committee considering polypropylene Mesh implants concluded:

It is not surprising, therefore, that those who have experienced harm from healthcare may feel that they are not being listened to.

In the same week another example featured in a week long series of articles in the Herald: “A Bitter Pill”. On a background of ever increasing prescribing of antidepressants it appears that my profession is still struggling to accept the value of people’s experience (which may not always be positive) and can respond defensively:

One responder has already articulated my feeling about this:

My understanding is that this series in the Herald arose, at least partly, because of a petition to the Scottish Parliament which seeks consideration of prescribed drug dependence and withdrawal.

One of the explanations for the rising prescribing of antidepressants is that people are often taking them for many years. Another way of looking at this is that people are not stopping these drugs. It is still the case that we really do not understand why this may be and we are not going to understand this until we listen to the experience of those taking these medications.

Experience is evidence and I find it incredible that we do not listen carefully enough to it.

 

 

 

 

Psychiatry without borders

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:

More details about a Sunshine Act for Scotland can be found here and here.

The public consultation can be found here.

 

Would you like to join me?

 

INVITATION:

This is an invitation to join me on a peaceful protest to be held on Monday 21st August 2017 at the Martyrs Monument, Calton Hill Burial Ground, Edinburgh.

WHAT THE PROTEST IS ABOUT:

It is a protest for anybody who has had difficulty communicating with high public office in Scotland. For some this may have been with the Scottish Government – but it need not relate to any particular institution.

This protest is for anybody who has felt that those in a genuine position of power may have acted unfairly.

Professor Walter Humes, writing in Scottish Review, 21st September 2015:

“For some time I have been copied into email exchanges concerning how complaints against public bodies are dealt with. I have no personal stake in any of the specific sources of concern (which include patient care in the NHS and responses by Police Scotland, the Scottish Government and the Crown Office and Procurator Fiscal Service (COPFS) to requests for formal investigations). I do, however, have a long-standing interest in issues of public accountability and am familiar with the various techniques used by bureaucratic organisations to avoid responsibility when things go wrong: these include silence, delay, evasion, buck-passing and attempts to discredit complainants.”

THE FIRST MINISTER’S “INTENTION”:

The First Minister for Scotland, Nicola Sturgeon said: “I intend that we will be an open and accessible Government” 26 November 2014

Prof Walter Humes, 21 September 2015:

“Those who hold high office in public bodies are very adept at defending their own interests. They may claim to support openness and transparency but those principles are not always translated into practice. Bureaucratic Scotland often falls short of the democratic ideals which are said to underpin civic life”

WHY GATHER AT THE MARTYRS’ MONUMENT:

This film by me, “The Friends of Liberty“, explains why the Martrys Monument has been chosen for this protest. The location is next to St Andrew’s House, the seat of the Scottish Government. The Martyrs Monument rises higher and has a wider view than St Andrew’s House. The Martyrs Monument was raised through public donations.

WHY the 21st of AUGUST ?:

Reason 1: The foundation stone of the Martyrs’ Monument was laid on this very day, 1844.

Reason 2: on the 21st August 2017 there will be a full solar eclipse (sometime just before 8pm) revealing the power of one orb over another and our shared need for light.

THE PERSONAL STORY MATTERS:

Here is my experience with Scottish Government. I have been, and continue to be, an active advocate for ethical considerations in all aspects of healthcare in NHS Scotland. I am proud of what I have done and of who I am.

So if you have your own story please come along and share it. Together we can make a difference.

Acknowledgement:
It was Mrs Chrys Muirhead who suggested the 21st August 2017 as 
date for this protest. Her enquiring mind had led her to find that 
this date was both an anniversary of the laying of the Martyrs 
Monument foundation stone and also the very day, in 2017, when 
a solar eclipse will occur.

 

 

 

Discontinuation of two different depot antipsychotics

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.

 

Stifling distortions












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The lawn was white with doctors









To seek balance in the appreciation of where expertise rests: my submission on PE01651

Submission on PE01651: Prescribed drug dependence and withdrawal

Made by Dr Peter J Gordon

Date of submission: 3rd June 2017.

Submission made in a personal capacity.

I am writing in support of this petition. I am an NHS Consultant Psychiatrist who has worked in this specialty in Scotland for almost 25 years now. My wife has worked as a General Practitioner in Scotland over the same period. I have an interest in ethics, human rights and the medical humanities generally. One of the areas I have taken much interest in is informed consent.

I would argue that this backdrop may mean that I can add some thoughts and reflections that might help the Committee in the consideration of this particular petition.

I should make it clear that as an NHS psychiatrist I do prescribe antidepressants and other psychotropic medications. I try to do so following the best available evidence as considered as relevant or not to my professional understanding of each unique patient and their life circumstances.

I wish to keep this summary short as I am aware that the Committee receives a great deal of evidence. So I offer a few points of evidence that I would be willing at a future date to expand upon if that were felt to be helpful:

• Antidepressant prescribing In Scotland (ISD figures) has been rising year-on-year in Scotland for at least the last ten years (this is also true of all other prescribed psychotropic medications). It is estimated that 1 in 7 Scots are now taking antidepressants and many of these in the long-term.

• At a recent Parliamentary Cross Party Meeting on Mental Health and older adults an invited speaker stated that: “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.”

• A key opinion leader and Government advisor has previously argued that prescribing of antidepressants in Scotland is “conservative” and “appropriate”.

• Many of the key opinion leaders “educating” doctors prescribing antidepressants in Scotland appear to have significant financial interests with the makers of these medications. Across the UK, £340 million was paid by the pharmaceutical industry in the last recorded year to healthcare workers and academics for such “promotional activities”.

• “Informed Consent” will not be possible if the information that doctors base prescribing on follows such promotion rather than independent, and more objective, continuing medical education. This issue is now at the fore of the Mesh Inquiry.

A few questions that need to be considered:

  • When patients are prescribed antidepressants are they informed that as many as 1 in 2 will be taking antidepressants long-term?
  • Are patients informed that there may be a significant risk of pharmacological dependence on antidepressants?
  • Do patients know that their experience of antidepressants may be considered less valid than the experts (who may have been paid by the pharmaceutical industry) who educate other doctors (who may be unaware of this potential financial bias)?

Summary:

My view is that antidepressants are over-prescribed in Scotland.

My view is that patients have not been properly informed of benefits and risks.

My view is that appropriate prescribing has not been realised due to a number of factors: the lack of access to psychological therapies or other meaningful supports; the wide promotion of antidepressants where marketing is routinely conflated with education; and a culture of increasing medicalisation generally.

I would suggest that this petition might be considered in light of the Chief Medical Officer’s Realistic Medicine campaign. It is time for balance to be re-established between “medical paternalism” and the valued, vital and real-world experiences of patients who are taking medications like antidepressants. I am particularly disappointed in my own College, the Royal College of Psychiatrists for not making greater effort to facilitate such balance. Without such, I fear more harm will result from inappropriate and costly prescribing in NHS Scotland.

Finally, due to widespread “off-label” promotion of antidepressants in Scotland, patients may experience withdrawal syndromes which can be most severe and precipitate mental states far more serious than the mental state for which they may have originally been prescribed.

I would urge the committee to consider this petition most carefully and to seek balance in their appreciation of where expertise rests.

Improvement science and consent: a failure of NHS Governance

I am an employee of NHS Lothian and have been ‘sign posted’ to the “New Capacity and Consent intranet page: important information for all staff.”

This is a screenshot taken on Friday 2nd June 2017:

The Capacity and Consent intranet page begins by reminding all NHS Lothian staff of the ‘Obtaining Consent’ Policy (2014):

The NHS Lothian ‘Obtaining Consent’ Policy (2014) informs staff that “failure to secure consent may constitute assault under common law in Scotland”.

All NHS Lothian staff are also reminded that “acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not consent”.

Two years ago I wrote about national improvement work undertaken by Healthcare Improvement Scotland for older people in hospital in NHS Scotland and my concern that “compliance” had replaced consent.

Given my experience that the guidance from my employers (NHS Lothian) on consent and the explicit requirements of “compliance” mandated by Healthcare Improvement Scotland seem to go in opposite directions, I wrote seeking further guidance. I have had this reply from Healthcare Improvement Scotland.

In conclusion: I would suggest that a failure of NHS Governance in Scotland has led to a confusion about the rights of older people to give consent.

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