Some immediate reactions

The Royal College of Psychiatrists Position Statement on antidepressants and depression was published on the 30th May 2019. Following its publication there was immediate reaction. Here are some of them:

[1] Position Statement on Radio 4: “a very small number”

The Registrar of the Royal College of Psychiatrists, Dr Adrian James, was a guest on the Today show on Radio 4. It is interesting to compare what was said in this radio interview with the position statement itself:

John Humphrys: “Pills to deal with depression can have severe side effects and doctors should warn their patients about them, that is what the Royal College of Psychiatrists will say today. It could severely cut the use of pills and many people would say about time too. Well Dr Adrian James is the Registrar of the Royal College of Psychiatrists. Good morning to you.”

Dr Adrian James: “Good morning”

John Humphrys: “Eh, what should be done therefore?”

Dr Adrian James: “Uh, well the really important thing John is that depression is a really serious condition, uh it causes a great deal of distress and suffering it really can effect people’s lives, their work, their families, and it is very important that they seek treatment for depression and there are effective treatments, and for more mild depression normally that is psychological treatments but for the more severe types of depression antidepressants are very effective often in combination with psychological treatments.”

John Humphrys: “But they do have, or can have, very severe side effects”

Dr Adrian James: “Well like all drugs eh there are side effects, and it’s absolutely . . .” [interrupted by interviewer]

John Humphrys: “. . . well you can become addicted to them that is the point isn’t it?”

Dr Adrian James: “eh, the, the majority of people will have either mild side effects or they will be self-limiting. And the purpose of the our, em, the thing that we published today, uh was that we didn’t think sufficient emphasis had been placed on some patients, a very small number, who had more severe withdrawal effects over a longer period of time. And we are saying that there should be more opportunity to discuss that with their doctors; look at things like tapering over a short period of time, that is gradually reducing the dose, and so that there is an honest debate and that there is an honest discussion with patients.”

John Humphrys: “Because we do hear increasingly don’t we of people, Sarah Vine for instance the columnist in the, eh, Daily Mail has written very powerfully about the effects on the drugs on her and she has not been able to give them up.”

Dr Adrian James: “Uh well, we do know that some people are on antidepressants for a long time, eh, that is sometimes very necessary. We also hear reports also in the press about people who have intractable depression, or depression that goes on for which they require antidepressants so, and eh depression is a really serious condition and it is treatable. Some people will need treatment over a long period of time, but like all medications there will be some people who will have side effects and absolutely you should have that discussion with your doctor.”

John Humphrys: “But is it possible that too many doctors, not all of course, but too many doctors are prescribing them when perhaps they shouldn’t be. I am looking at the statistics: there has been an enormous rise in the prescription of medication – 36 million eh, to 70 million last year. I mean that is a significant increase isn’t it.”

Dr Adrian James: “Eh there has been an increase ah, but the evidence shows that only about a third of people who could benefit from evidence-based treatments for mental health as a whole actually get those treatments. So, the real story here is that there is still not enough access to treatments – so I think patients want a range of treatments, they want choice – and what has often been missing has been the alternatives, so things like psychological therapies, now hey have increased a lot and that is a very positive thing. But we actually need a massive investment in mental health, we have had some investment and that is very good, but this is the start of a journey. So we need a range of options but actually we need doctors to talk to patients about side effects, the risks and the benefits, but I would not want anybody to be discouraged from taking antidepressants because depression is serious, anybody who has experienced depression will know that, and antidepressants are effective. But yes we do need to have an honest discussion about side effects.”

John Humphrys: “Dr Adrian James thank you very much”

[2] Position Statement: “the so called withdrawal reactions”

In an Expert Statement for the Science Media Centre, Professor Allan Young, King’s College London, offered this opinion in relation to the Royal College of Psychiatrists Position Statement on antidepressants and depression:

“Antidepressants, like all drugs, should be taken as per best advice. So called withdrawal reactions are usually mild to moderate and respond well to simple management. Anxiety about this should not obscure the real benefits of this type of treatment.”

The Editor-in-Chief of the BMJ, Fiona Godlee, recently said:

Professor Allan Young is a good example of the present:

Professor Allan Young  has given paid lectures and advisory boards for the following companies with drugs used in affective and related disorders: Astrazeneca, Eli Lilly, Lundbeck, Sunovion, Servier, Livanova, Janssen, Allegan, Bionomics.

Professor Allan Young is paid Consultant to Johnson & Johnson and paid Consultant to Livanova

Professor Allan Young has received honoraria for attending advisory boards and presenting talks at meetings organised by LivaNova.

Professor Allan Young is an Investigator in research for Astra Zeneca, Eli Lilly, Lundbeck, Wyeth, Janssen.

Professor Allan Young is a member, and recent Past President of, The Royal College of Psychiatrists Psychopharmacology Committee.

Professor Allan Young is President of the British Association for Psychopharmacology

[3] Position statement: frequency of withdrawal reactions

Dr Sameer Jauhar in offering public support of the position statement was concerned about the media coverage:

“I do not understand how and why people make up numbers like this. Every individual is important- you don’t need to give erroneously high numbers to highlight the problem”.

Dr Jauhar, with Dr Joseph Hayes as co-author, were cited in the position statement. These authors have criticized the research methodology of Professor James Davies and Professor John Read on the frequency of withdrawal reactions. The Mental Elf  has stated that Hayes and Jauhar “set the record straight on antidepressant withdrawal”.

In a recent paper “Antidepressants, withdrawal and addiction: where are we now?” Jauhar et al claim that the frequency of withdrawal reactions for paroxetine (probably the worst drug in respect to withdrawal) is only 23%. However this withdrawal rate of 23% for paroxetine is flawed because it is based on 3 short-term (12-24 weeks) efficacy studies with carefully pre-selected, unrepresentative samples. Most importantly, timing of drug discontinuation was not randomised. In another study by Rosenbaum et al. participants were on paroxetine for about 12 months on average, which is much more representative of real-world practice than the short-term trials analyzed by Jauhar et al.  In this study, 66% of patients experienced a withdrawal reaction in the paroxetine arm (vs. 60% for sertraline and 14% for fluoxetine). In a study by Michelson et al using similar methodology and length of treatment before discontinuation (mean: 16 months) largely confirmed the high incidence of withdrawal symptoms after discontinuation of paroxetine vs. active treatment (57% vs. 6%)

It would seem then that the incidence rate of  withdrawal reactions for paroxetine is, in reality, much higher than the 23% quoted by Jauhar et al.

Following the publication of this paper one of the co-authors, Professor David Nutt said “here is the definitive overview of antidepressant withdrawal just out today”. Professor Allan Young is another co-author and his recent expert view for the Science Media Centre began “[these] so called withdrawal reactions . . . “. Last year Professor Young, as President of the British Association for Psychopharmacology awarded Dr Jauhar the Senior Clinical Award. BAP has recently confirmed that Dr Jauhar has won another award for this year.

Rhiannon Cosslett, a Guardian Columnist, in a piece titled “I know antidepressant withdrawal symptoms are real. Why didn’t doctors?” recently said:

“It is too easy to simply state that doctors need to listen more to patients in cases such as these. Proper research needs to be conducted. But it is telling that patient stories weren’t enough to bring about change to prescribing and withdrawal guidelines: that has happened only because clinicians such as Professor David Taylor, who also happened to be a patient, have experienced withdrawal and studied it as a result. Taylor told the New Yorker that had he not suffered withdrawal, he probably would have accepted the standard guidelines.”

The lack of research on the effects of withdrawal by pharmaceutical companies rushing their medicines out into the world is also undoubtedly a factor. As is the minimising by drugs companies of such research that does exist – ‘highlight the benign nature of discontinuation symptoms, rather than quibble about their incidence,’ read one internal memo seen by the New Yorker.” 

[4] Position Statement: “a top priority on our research agenda”

In an Expert Statement for the Science Media Centre, Professor John Geddes, University of Oxford offered this consideration in relation to the Royal College of Psychiatrists Position Statement on antidepressants and depression:

“This initiative by the Royal College of Psychiatrists is timely because there currently a great deal of discussion and uncertainty across social media, conventional media and in the scientific literature about withdrawal symptoms from antidepressants. As clinicians, it’s important that we make sure patients are aware of the evidence we have on antidepressant withdrawal. And it’s important that NICE conduct a robust and thorough assessment of all the available evidence to understand the incidence and clinical implications of the distressing and sometimes devastating adverse effects that some patients report when coming off antidepressants. This is a top priority in our own research agenda and we are in the process of collecting data not only from studies conducted by the pharmaceutical industry, but also from population registries and survey with people with lived experience of depression and antidepressants.”

Professor Geddes states that this area –“the devastating adverse effects that some patients report when coming off antidepressants” – is a “top priority in [Oxford’s] research agenda”. The hyperlink given to support this is to the SUSANA Survey. Yet this survey does not include considerations of dependence on, or withdrawal from, antidepressants. I shared my concerns about this with one of the Study Coordinators, Professor Andrea Cipriani of the University of Oxford on the 29th May 2019.

[5] Position Statement: “FACTS”

The  very same day as the College Position Statement was published  the President, Registrar and CEO of the Royal College of Psychiatrists were speaking at this accredited Continuing Medical Education event for psychiatrists:

One of the “Invited Lectures” was given by Professor Allan Young who gave a talk titled “Myths about mood disorders”. For the Science Media Centre [where science meets the headlines], Professor Allan Young offered this expert opinion in relation to the Royal College of Psychiatrists Position Statement on antidepressants and depression: “Antidepressants, like all drugs, should be taken as per best advice. So called withdrawal reactions are usually mild to moderate and respond well to simple management. Anxiety about this should not obscure the real benefits of this type of treatment.”

This slide comes from the Lecture that Professor Allan Young gave on the 30th May 2019 to his fellow psychiatrists:

One psychiatrist shared this summary slide by Professor Allan Young with 11 other UK psychiatrists stating: “summary slide on-antidepressants absolutely brilliant presentation – facts beating the myths”.

Further slides and comments made about the lecture can be seen here (I have taken copies in case they may be removed).

One attendee recorded this: “2/3rds of Briton’s don’t receive treatment for Depression #FACT. Antidepressant discontinuation reactions are preventable and treatable #FACT. So says Prof Young.” 

Another attendee shared that Professor Allan Young had stated “that withdrawal reactions can be managed and antidepressants can be withdrawn when needed in a safe way”

Another attendee recorded this: “Antidepressants are effective and well tolerated – Prof Young breaks the myths about mood disorders.”

[6] Newspaper reactions to the Position statement : ‘not a moment too soon’