‘Medicine remains a conflicted as ever’

In my previous post I shared a transcription of the latest podcast in the At the Back of Your Mind Series for Inspire The Mind:

In this post I would like to offer some thoughts on the content of this podcast. I will do so in the spirit of trying to encourage balanced debate that values all experience.

The fresh approach taken in this podcast is most welcome and the enthusiasm of the hosts shone through as did their determination, through their research, to reduce suffering. This podcast took on an important matter and the hosts did well to make a complex subject accessible and to carefully explain any technical terms.

I was interested in the following statement made in the podcast as it differs, significantly so, from what I understand is the official position of the Royal College of Psychiatrists:

Professor Pariante had ample opportunity in this podcast to make clear that these specific changes do not necessarily prove that any generalised theory is correct. Professor Pariante never once used the word theory. In terms of informed consent it is important, that when discussing any potential intervention with any patient, that healthcare professionals are clear what information is based on theory and what is not. The philosopher, Mary Midgley, wrote about this subject in her books about medical ethics and she also advised us to carefully question reductionist language used to describe the astonishing complexity of life.

The hosts of this podcast began:

I would not disagree that mainstream media often use sensational headlines that lack in nuance. However, we should not simply assume that academics or professionals are neutral in what they put across in the media. Professor Pariante provides a case in point.

When this meta-analysis was published and reported in the media:As a key opinion leader and one of the most influential psychiatrists in the UK he was quoted across the UK, and the Science Media Centre ensured that this, his expert opinion, was disseminated across the world.

I have previously outlined my understanding of what this meta-analysis could or could not say. I was disappointed that the authors and the experts giving opinions made little effort to clarify that this study is based on short-term, 8 weeks studies for severe depression (not mild or moderate) and that it does not provide evidence for longer term prescribing. It should have also been made clear that this study was based on whether antidepressants, taken over 10 weeks were “tolerated” or not, and had nothing to say about the experience of side-effects.

Dr Margaret McCartney and Dr Mark Porter expressed similar concerns in “Inside Health” on BBC Radio 4.

Dr Mark Porter: “And talking of the real-world, the other thing that struck me about this was the average duration of antidepressants when they looked at antidepressants in the study was just 8 weeks, and you and I know that the average course, in fact the minimum course is something like 9 months”.

Dr Margaret McCartney: “Oh at least, and one of the big problems that we have, as yet unanswered, is what is the effect of taking these drugs perhaps on and off, mainly on, for years at a time and that is where we have real deficits in our information, it is really tragic that so many trials have been done looking at the short term when the real life use is of months and even of years. It is really appalling that decades have passed without us asking the fundamental question of how we are using them today and whether that is safe and effective, good practice or not.”

I believe that it is important for us to consider perspectives from generalists  such as Dr Porter and Dr McCartney who are also regular commentators on a very wide-range of health issues.

Returning to the current podcast on antidepressants, it was welcome to find that Professor Pariante acknowledged withdrawal effects from antidepressants [though he seemed to question, or at least suggest concerns about the validity of withdrawal experiences, by using the term ‘subjective‘]:

What Professor Pariante presents here misses out essential history, indeed he makes it sound like withdrawal effects have always been openly recognised by psychiatry. The reality is quite the opposite. Psychiatric orthodoxy, for at least 30 years since the time of the Defeat Depression Campaign, was this:

25 February 2018: a Letter in the Times by the President of the Royal College of Psychiatrists and the Chair of the College’s Psychopharmacology Committee:

What follows is a timeline of responses made by influential UK doctors in the immediate period after this letter:

27 February 2018, Dr Samei Huda: “The rise in the use of antidepressants isn’t because people are struggling to get off but because doctors are following the evidence which shows that antidepressants prevent relapse which is common in depression.

10 March 2018, Professor Louis Appleby: “Antidepressants work.  They are not placebo, they are not addictive. Emphatic from Dr Clare Gerada on BBC Radio 4. Dangerous to suggest otherwise.”

26 April 2018, Professor Clare Gerada: “We are prescribing more antidepressants and I think quite rightly.”

26 April 2018, Professor Clare Gerada: “I can count on one hand the number who have gone on to have long term problems withdrawing from antidepressants or problems coming off antidepressants.”

4 April 2019, Dr Samei Huda: “The increase in prescriptions of antidepressants is due to use in pain, more people seeking treatment and longer duration to prevent relapse.”

The following Position Statement by the Royal College of Psychiatrists was published in May 2019 :Following the publication of this Position Statement, responses continued:

30 May 2019, Professor Allan Young: “So called withdrawal reactions from antidepressants are usually mild to moderate and respond well to simple management.”

9 January 2020, Dr David Foreman: “If someone needs an antidepressant to remain symptom free then the dependence relates to the disorder, not the drug.”

6 June 2020, Professor Robert Howard:  “Antidepressant withdrawal is rare and not the issue that some are suggesting.”

7 June 2020, Professor Robert Howard: “The experience of many of us – who follow our patients after discontinuation – because we have always been worried about relapse – has been that withdrawal phenomena are not common and generally resolve quickly.”

22 June 2021, Dr Mark Bolstridge: “The vast majority don’t experience withdrawal from antidepressants.”

2 November 2021, Dr Mark Bolstridge: “There isn’t a dependence syndrome associated with SSRI antidepressants.”

Returning to the podcast, towards the end of the recording, the hosts reflected on Professor Pariante’s contribution:

It was disappointing then to find that expert contributors to these podcasts, and indeed to Inspire the Mind generally, are not asked to share potential competing interests. Let it be clear there is no statutory requirement to do so, but if science is to pursue the ideal of ‘disinterestedness’, as it should, then competing interests, that have been proven to introduce bias, should be fully declared.

I have no wish to single out Professor Pariante, but it is the case that as a key opinion leader in psychiatry, his partnerships, paid or otherwise, with industry are extensive:

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It is indeed a challenge for us all to ensure the information provided to us is as factual as possible. Inspire the Mind states on its homepage:

Here are some of the paid opinion leaders in UK psychiatry [I have used information available in the public domain to construct visual summaries of the competing interests of some key opinion leaders. I have done so in the spirit of the relevant guidance of the Royal College of Psychiatrists].

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Please note: The title of this post comes from an article by Dr Margaret McCartney published in the BMJ on 27 May 2022.