Rising stars: British Association of Psychopharmacology

I submitted a rapid response to the BMJ last September after viewing galleries of photographs of the British Association of Psychopharmacology (BAP) Summer Meeting of 2016. The BMJ did not publish my post. This year’s galleries of the British Association of Psychopharmacology (BAP) Summer Meeting have now been shared. This is an amended version of what I sent last summer:

I was recently shared the published photographs of the British Association of Psychopharmacology 2016 Summer Conference.

At this BAP conference, an accredited CPD conference, the rising stars are seen to mix with today’s key opinion leaders. We all welcome the sharing of experience between generations and I have repeatedly stated how important I believe this to be. Some of the BAP key opinion leaders have declared significant financial interests with the Pharmaceutical Industry.

Up-to-date declarations of BAP speakers can be viewed here

I support transparency.  I have understood that this can only ever be a means to an end.

Robert K Merton once insisted that science should be based not on interest but ‘disinterest’. Merton’s star rose long ago and he is now dead. I do hope that all generations of scientists might be able to see his ‘disinterested’ star, still in the sky that we all share.

 

The Scottish Public: consulted on a Sunshine Act

The Scottish public were consulted on the need for a Sunshine Act for Scotland. Their response, in majority, was that this was necessary.

Almost a year-and-a-half on and the Scottish Government has provided no update to the Scottish people. This is disappointing given the Scottish Government’s assertion that “everyone matters” to them.

The lack of sunshine legislation in the British Isles is raised in this current BMJ News feature:

This response was submitted by Vagish Kumar L Shanbhag:

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.

 

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.

Continuing Medical “Education”

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.

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

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.

A letter to Professor Jason Leitch

Image

In this post I reply to Professor Jason Leitch, whose letter of the 2nd June 2015 on Haloperidol prescribing to Scotland’s elderly can be read here:

Jason Leitch Delirium

This is the link to my summary on Delirium Screening written March 2014 at the request of one of those involved with improvement work in delirium. I shared this with Healthcare Improvement Scotland, the Scottish Delirium Association and OPAC (Older People in Acute Care Improvement programme). I had no replies.

Recently this automated e-mail arrived:

Jason Leitch, unread letter deleted

I thus contacted Professor Leitch to clarify. This is the response I received:

e-mail: 25 September 2015 

Dr Gordon, I can assure you that not only did I receive and read 
your email of 8th June, I still have it. I noted its content and 
following our earlier correspondence didn’t feel it required a 
response. I also read our correspondence which you published 
on your blog. 

Professor Jason Leitch, National Clinical Director.

The following behind-the-scene communications were recently released as a result of a Data protection request. The communications indicate a tone of disdain for those who may write regularly to DG Health and Social care.

director-general-of-nhs-scotland-e-mail-to-jason-leitch-national-clinical-director-who-is-not-registered-with-the-gmc

I had asked if Professor Jason Leitch might confirm if he is registered with the General Medical Council. Again there is clear evidence of a most disparaging tone made by two of the most senior figures in the DG Health and Social care. One has to worry for other correspondents who write with legitimate concerns about patient wellbeing and safety.

communications-between-deputy-director-nhs-scotland-and-national-clinical-director-25-sept-2016

Professor Leitch chose not to answer my question about registration with the General Medical Council however he did kindly supply a most abbreviated CV which would indicate that he is not medically trained and qualified. Professor Leitch’s qualifications are in Dentistry and he is registered with the General Dental Council. This is important in that Professor Leitch gives advice as National Clinical Director for NHS Scotland yet he is governed by a regulatory body that is not for general medicine.

national-clinical-director-and-director-general-25-sept-2016

 

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.

“In pursuit of marketing approval” [antidepressants for anxiety]

This is a report in the current BMJ:  Publication bias01This was the result of the pursuit of the market:Publication bias02The US Food and Drug Administration failed to ensure scientific objectivity:Publication bias03Robert K Merton would weep at this.

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.