Tuesday, 30 December 2014

On The Wrong Track - Peter Gøtzsche - Psychiatric Epidemic - 14 May, 2014, Copenhagen Video




"Published on Jun 10, 2014
Dr. Peter C. Gøtzsche is the head of the Nordic Cochrane Center. His book, "Deadly Medicines and Organised Crime" was published last year. Peter is speaking here at PsykoVision's conference on The Psychiatric Epidemic in Copenhagen."

---------------------------------------------

Tweets with screenshots from video:







Tuesday, 23 December 2014

'Young children given hyperactivity drugs ‘against NICE guidance’' PULSE

'Young children given hyperactivity drugs ‘against NICE guidance’', Caroline Price, 22 December 2014, PULSE:

"Pre-school children are being prescribed drugs such as ritalin for hyperactivity, contrary to NICE guidelines, warn child psychologists who say under-funding of child services is to blame.

Researchers found more than a fifth (22%) of educational psychologists were aware of pre-school children taking stimulant medications – despite NICE guidelines saying children under five should not be prescribed them.

The study based on a survey of 136 educational psychologists working in the UK, was carried out by researchers from the Division of Education and Child Psychology (DECP) at the British Psychological Society, and the Institute of Education at the University of London,

The staff surveyed said pressures on child and adolescent mental health services (CAMHS) meant children were not being properly assessed, and there was a rush to treat attention deficit hyperactivity disorder (ADHD) with medications rather than trying psychological interventions first, as NICE advises.

Our biggest difficulty is that CAMHS and paediatric teams are so short staffed they go straight to medication and completely ignore NICE guidance,’ a DECP briefing said.

The survey also found educational psychologists felt that ‘intolerance of difference’ and ‘medical models of childhood’ were influencing how children’s learning and behaviour are viewed.

Psychologists were quoted as saying: ‘There is an increasingly prevalent view in society that people who do not fit a particular environment must have something wrong with them.’

The briefing was produced in preparation for the DECP’s annual conference being held in early January, when the DECP ‘medicalisation working group’ will publish a position paper and professional practice guidelines on the diagnosis and management of ADHD.

It comes after Pulse found GPs were struggling to refer children with behavioural or emotional problems for proper assessment at CAMHS following cuts to child mental health budgets, amid plans to make even further cutbacks."


Monday, 15 December 2014

Reblog: NHS Tayside – Update on Registers of Interest for all staff, Dr Peter J Gordon

NHS Tayside – Update on Registers of Interest for all staff Hole Ousia blog post by @PeterDLROW:


Ms Lesley McLay
Chief Executive,
Tayside Board Headquarters,
Level 10,
Ninewells Hospital and Medical School,
Dundee,
DD1 9SY

15th December 2014

Dear Ms McLeay,
I am writing to seek further update on NHS Tayside’s compliance with HDL(2003)62. I am concerned that NHS Tayside do not seem to be fully complying with this Scottish Government Guidance. I shall briefly set out what NHS Tayside has confirmed on this matter.

I first wrote to NHS Tayside about this in February 2013. This was part of writing to all 22 NHS Boards in Scotland.

I was told: “I wish to confirm that NHS Tayside will have a commercial sponsorship register available in a format suitable for being made public by week ending 31 January 2014.” 

NHS Tayside supplied a PDF file entitled “Public Record of Sponsorship”. I can find no link to this on the NHS Tayside website. Perhaps I may not be looking in the correct place? This is a screenshot of, what seems to be, the relevant NHS Tayside page. It links ONLY to BOARD members interests:

NHS-Tayside-web-15-Dec14

The “Public Record of Sponsorship” has 16 entries by individual employees of NHS Tayside (as some individuals have made several entries). 16 entries from 2011 to the end of 2013. This is a surprisingly small number. There were only two staff entries in 2012.

The “Public Record of Sponsorship” does not name staff but only gives designation (see sample below from one of the 2 pages of your “register”)

Public-record-of-sponsorshi

In April of this year, NHS Tayside confirmed the following to the Scottish Government:

NHS-Tayside-Apr14

Ms McLay, I would welcome your thoughts on:

(1) NHS Tayside’s compliance with HDL (2003) 62

(2) Your view as Chief Executive whether NHS Tayside’s “Public Record of Sponsorship” is a complete and accurate record of financial payments made to all employees of NHS Tayside?

I would be grateful if you could provide me with the public link to NHS Tayside’s “Public Record of Sponsorship” for all staff.

Yours sincerely
Dr Peter Gordon

Reblog: NHS Grampian – Update on Register of Interests for all staff, Dr Peter J Gordon

NHS Grampian – Update on Register of Interests for all staff Hole Ousia blog post by @PeterDLROW:


Malcolm Wright
Interim Chief Executive
NHS Grampian

Summerfield House
2 Eday Road
Aberdeen

15th December 2014

Dear Malcolm Wright,
In July 2013 I had a most helpful response from Andrew Jackson on behalf of NHS Grampian in terms of my question (that I put to all Scottish NHS Boards) about a publicly accessible Register of Interests for ALL staff.

I have picked out two sentences of this reply that indicate that NHS Grampian had no such Register for all staff and as such was failing to comply with HDL (2003) 62:

“…no such register is maintained and therefore a copy is unable to be provided to you….In all of the circumstances therefore, NHS Grampian is unable to provide a register to meet your requirements.”

NHS Grampian provided an update to the Scottish Government in April 2014. I include it below:

NHS-Grampian-April-2014

I would be interested in hearing how NHS Grampian are progressing with this, 18 months on from my original FOI enquiry.

As a reminder, I append below, Scottish Government Circular HDL (2003) 62 and what it asks of Chief Executives.

For transparency to be meaningful I would argue that Registers need to be publicly accessible through each NHS Board’s website. NHS Forth Valley are doing this: http://nhsforthvalley.com/publications/policies-and-procedures/

Yours sincerely

Dr Peter J. Gordon

HDL-62

alex-neil-on-reg-of-interes


Sunday, 14 December 2014

Reblog: NHS Ayrshire & Arran: Update on Register of Interest for all staff, Dr Peter J Gordon

NHS Ayrshire & Arran: Update on Register of Interest for all staff Hole Ousia blog post by @PeterDLROW

"Subject: Compliance with HDL (2003) 62

Mr John Burns

Chief Executive
Eglinton House
Ailsa Hospital
Ayr

14th December 2014.

Dear Mr Burns,

In April 2013 I wrote to NHS Ayrshire & Arran about Registers of Interest for ALL staff. In a written reply, dated 31 May 2013, I was told by Ann Catherine Wilson “There are no payments from pharmaceutical companies on the register of interests.” This was stated in relation to a link to Board Members Registers of Interest.
 
I wrote back to NHS Ayrshire & Arran, pointing out that this Register was for Board members only.

I had a reply on the 11 June 2013 from your organisation:

“Discussions are ongoing to create a register to encompass the whole organisation … we are in the process of updating our Model Publication Scheme to include this register which will be published on our public website.”

A more recent reply to the Scottish Government (letter dated 14 April 2014). Below is the relevant section for NHS Ayrshire and Arran:

Ayrshire-&-Arran-17-4-14

I would be most grateful if you could update us on progress made on HDL(2003) 62 and whether you have, as promised “create[d] a register to encompass the whole organisation” that NHS Ayrshire & Arran would “publish on our public website.”

Yours sincerely
Dr Peter J Gordon

(Petitioner for A Sunshine Act/Clause)

*Appended below is HDL(2003) 62 and what the Scottish Government asked of Chief Executives."

HDL-62

Tuesday, 9 December 2014

Reblog: Dr David Healy 'Persecution: Professional SUI Cide' 8 Dec 14

Dr David Healy blog post 8 December 2014: 'Persecution: Professional SUI Cide

"This is the Fourteenth in the Persecution Series, after The Persecution of Heretics, The Persecution of Vulnerable Adults, Harassment from the BBC to GMC, Harassment from Rolf Harris to James Coyne to Doctor WhoPersecution: Black Riders in the Shire  & Persecution: Rumbles from Mordor, and eight in the SUI Cide Series SUI Cide in Betsi, SUI Cide Trick or Treat , The SUI Cide Note & SUI Cide or HomicideSUI Cide in the OK Corral. SUI Cide & Peace in our Time, The SUI Cide Apparatus.  A new subseries, the Pharma series begins next week."

Intro
"For some of us, the magic of boarding an Alaskan Airlines flight from Anchorage to Atlanta with 200 other people and all their baggage, or even bigger planes aiming at crossing 12000 miles of Pacific Ocean, and finding that the thing actually lifts off the ground never fades.

Any sane thinking person should be reduced to a state of gibbering panic for the duration of the flight, but most of us put our trust in the woman at the controls and in the fact that if we don’t get there she won’t.  If she had significant concerns she wouldn’t now be taking off.  While aviation safety systems aren’t perfect, if the near misses or other glitches she and her colleagues report aren’t taken care of, no one gets anywhere until the problem is sorted because she won’t fly."

Excerpts

"Almost by definition then a good doctor has to be someone who knows when not to poison or mutilate or someone who, when things go wrong, can quickly respond with “what do you know, we gave you a poison and you’ve been poisoned, let’s see if between us we can work out where to go from here”."

"Psychiatry is the Sister who has got to the Ball first time after time and got her man.  But this time the Prince seems completely uninterested.  The options – suicide with a glass sliver or turn into an Ugly Sister?

If not one of these two options, psychiatry has to achieve another first.  Its task is not, as the current President of the Royal College of Psychiatrists in Britain would have it, to get more psychiatry to people. Its task is to get to a position where people recognizing a real benefit might in a truly voluntary manner seek out psychiatric input.  It has to find if there is anything about it, other than its police function, that can’t be provided by a good primary care generalist or a psychotherapist. It has to find true love."

"We don’t want every psychiatrist to go down with the ship and retire from practice or commit suicide if a patient commits suicide or to take into their care the patient with an autistic spectrum disorder born to a mother he has put on an antidepressant while pregnant, but we don’t want Korean ship captains either ..."


Read complete blog post



Wednesday, 3 December 2014

Reblog: 'Seeking Transparency' Dr Peter J Gordon #HoleOusia

Reblog: 'Seeking Transparency' by Dr Peter J Gordon @PeterDLROW #HoleOusia

"Over a year has passed since I had an uncomfortable experience at work through trying to encourage transparency regarding pharmaceutical sponsored medical education.

Over that period of time, despite wider discussion, I am not sure that very much progress has been made, and for this reason I think it would be helpful to share my experience.

I have for several years now collected examples of sponsored medical education across the UK. This was my individual effort to aid general transparency.  The pinterest board automatically generates a tweet of new posts.

The following sponsored education was circulated in August 2013 by a senior medical manager of NHS Forth Valley to medical staff. I posted the flyer on the pinterest board as I have done with all other examples of sponsored medical education that came my way."


ADHD Academy as cascaded by AMD, Dr Rhona Morrison, Aug 2013
"A few weeks later I received  a letter from the senior medical manager concerned that formally expressed concerns that my “behaviour” had been “offensive and unprofessional”. This letter was also sent to more Senior Managers and as a result I was summoned to a meeting and encouraged to “reflect on my behaviour”.

I shared my unpleasant experience with a friend at the time, who remarked “Can a person be disciplined for taking an ethical position in the interest of the public/patients good?”

I have reflected at length about my experience. I remain puzzled by the degree of defensiveness generated simply by recording sponsored medical education. I am also disappointed in how unwelcome my efforts to achieve transparency have seemed to be to my colleagues."

Saturday, 29 November 2014

Dr Peter J Whitehouse: "Why I no longer consult for drug companies" #Omphalos Dr Peter J Gordon




Why I no longer consult for drug companies from omphalos 

"This film carries some of the words by Dr Peter J. Whitehouse in a paper that he wrote called "Why I no longer consult for drug companies" published in Culture, Medicine and Psychiatry, March 2008, Volume 32, Issue 1, pp 4-10  

link.springer.com/article/10.1007%2Fs11013-007-9075-x#page-1

I wish to thank Dr Whitehouse for allowing me to use his words in this film.

I have made this film as I share Dr Whitehouse's concern about the entanglement of pharmaceutical marketing/health industries with continuing medical education. I also share concern that when it comes to the Key opinion leaders in dementia that the talk of "transparency" is only talk. Last year £40 million was paid by Pharma to healthcare workers in the UK. Research into Scottish NHS Hospitality Registers evidences that payments from Pharmaceutical Industry are consistently not being declared in Registers (if indeed there is a functioning NHS register!) We are in the dark about this. Unlike USA we have no 'Sunshine Act.' The UK has a meaningless, one-sided, code called the ABPI code.

holeousia.wordpress.com/2013/08/08/to-alex-neil/

I admire Dr Whitehouse enormously. Dr Whitehouse's transparency is most special and marks him out as a doctor of utmost integrity. Dr Whitehouse is a rare breed, a polymath and Phronimos whose empathy reaches me across the Atlantic.

Dr Peter Whitehouse is Visiting Researcher and Strategic Advisor in Innovation, Baycrest, University of Toronto.

Professor of Neurology and former Professor of Psychiatry, Neuroscience, Psychology, Cognitive Science, Bioethics, Nursing, History, and Organizational Behavior, Case Western Reserve University. Physician, University Hospitals Case Medical Center. And Director, Adult Learning, The Intergenerational School.

Music thanks to Dexter Britain which can be shared under common-licence:

(1) "Nights Tale" by Dexter Britain (dexterbritain.co.uk)
(2) "The Tea Party" by Dexter Britain (dexterbritain.co.uk)
(3) "Seeing The Future" by Dexter Britain (dexterbritain.co.uk)"

My comment on video:

"Very good film Peter and well done to Peter Whitehouse for being honest about getting taken in by Big Pharma.

"they were trying to manipulate my opinion"  Yes they were. 

And I agree that we do need a Sunshine Act. I hope that Scottish Parliament will see sense, grasp the nettle, respond positively to your petition and do the business of introducing it as law:

scottish.parliament.uk/GettingInvolved/Petitions/sunshineact


Tuesday, 25 November 2014

Registers of Interest: @NHSGGC @NHS_Lothian @NHSLanarkshire, Dr Peter J Gordon, Hole Ousia

Dr Peter Gordon @PeterDLROW):

"As petitioner for the Sunshine Act I undertook Freedom of Information Requests to all 2(2 NHS Boards in Scotland to establish if Boards had  Registers of Interest for ALL staff. The findings revealed that most Boards did not."

Hole Ousia blog posts:
Hole Ousia

NHS Greater Glasgow – Register of Interest 



NHS Lothian – Register for all staff


NHS Lanarkshire – Register of Interest for all staff



Excerpts:

HDL-62
The above guidance, HDL 62, was issued by the Scottish Government in 2003:
“Chief Executives are asked to establish a register of interest for all NHS employees and Primary Care contractors”.


The British Medical Journal have recently covered this issue (19th July 2014):

BMJ-cover-19-July-2014---me


The Sunday Herald, published in Glasgow, gave this recent Editorial:

Herald-Editorial18-May-2014
--------------------------------------------------------------

Here is a screenshot of part of the Register for NHS Greater Glasgow:

CropperCapture[1]

NHS Greater Glasgow is the largest health board in the United Kingdom, serving 1.2 million people and employing 38,000 staff.

The above Register of Interest supplied by NHS Greater Glasgow covers 5 years and has entries for just 27 separate employees. One has to wonder how comprehensive and  how representative this register of Interests actually is?

--------------------------------------------------------------

NHS Lothian has  NO Register of Interests for all staff. This was confirmed in this Freedom of Information reply dated 6th May 2013:

May2013

--------------------------------------------------------------

The Medical Director for NHS Lanarkshire, Dr Iain Wallace, stated in writing on the 15th May 2014:

 “I can advise that it is not the intention of NHS Lanarkshire to publish a register of interests for all staff”


It's-time-patients-knew-Mgt


Sunday, 23 November 2014

Reblog: 'NHS Forth Valley – Hospitality Register 2013/2014' on Hole Ousia, Dr Peter J Gordon

[Reblog: NHS Forth Valley – Hospitality Register 2013/2014 on Hole Ousia  @PeterDLROW ]

"As petitioner for the Sunshine Act I undertook Freedom of Information Requests to all 22 NHS Boards in Scotland to establish if Boards had  Registers of Interest for ALL staff. The findings revealed that most Boards did not.

NHS Forth Valley has kept Registers of Interest from 2010 to current date. Following persistent enquiries by myself regarding public transparency these have recently been made available on-line.

This accords with the guidance in HDL 62, issued 2003: “Chief Executives are asked to establish a register of interest for all NHS employees and Primary Care contractors”. For this, and for taking the extra step of ensuring public access to the registers, NHS Forth Valley are to be congratulated.

This blog post encourages you to consider the contents of NHS Forth Valley’s Hospitality Register for 2013 to 2014 as an illustration of the involvement of sponsorship of Continuing Professional Development (“CPD”).

There is now robust research evidence that sponsorship influences clinical practice, no matter how much individual healthcare workers claim to be immune from such influence.

BMJ-cover-19-July-2014---me

We are all aware of straightened public sector budgets and so it is perhaps not surprising that external sources of finance are welcomed. In fact it would appear that:

“Yes, you’re correct – there is no NHS Forth Valley budget that pays for educational meetings held in the Centre.” Director of Medical Education for NHS Forth Valley, 25th February 2014

I would argue that this is a false economy adding to the risk of over-medicalisation and subsequent harm.
(the following is an example, showing just one page out of seven, from NHS Forth Valley’s Hospitality Register 2013-2014)"

CropperCapture[1]


Thursday, 20 November 2014

Reblog: “Believe me, that is not the way to get things done” Peter J Gordon, Hole Ousia

  
“Believe me, that is not the way to get things done” Peter J Gordon, Hole Ousia [Reblog]

"This post is about medical education in NHS healthcare: this is called “Continuing Professional Development” (“CPD”).

In this post I will explore the current relationship between medical education with commerce.

The title of this post is taken from a quote by the current Director of Medical Education for NHS Forth Valley in a communication to me on this matter.

As I get older I find that I see more patterns.

How we “see” such patterns will differ for us all!  My previous post was about a pattern that I had noticed regarding ageing and memory: The parabolic pattern

The pattern in this post is not one of light. It is a dark pattern. A pattern not easily seen.

Before trying to present light to this pattern, I want you to know that I am a scientist (as well as an artist) who supports innovation, scientific realism and progression. This is why the the Scottish physicist, and poet, James Clerk Maxwell has long been my guide.

The pattern of images that follow (where I will try to keep my words spare) represent my very real concern that science today (and not just “in the past”) has rather too readily become the pocket of industry.

It was Alexander McCall Smith who wrote to me recommending this book:

026
This week I faced a repeating pattern with this “educational” circular from my new employers:

014
Professor David Taylor is an Academic Pharmacist and so not registered with the General Medical Council. Prof Taylor has had significant input into the development of UK-wide guidelines on prescribing in mental health. He has been open about his significant financial conflicts of interest

018
Professor David Taylor, paid by the Pharmaceutical Company Janssen, had earlier this year, given an “educational” talk to CPD teaching with my former employers:

008
I refused to go to this. Why? Well through much of the previous 6 months, my NHS e-mail in-box had received e-mails (not at my request) from the makers of Asenapine. Several “key opinion leaders” featured in these promotions, including Professor Alan Young (whom more of later) and Prof David Taylor. The following slide comes from this online powerpoint:

 002
  
The next in this slide is exemplary of good practice as in it Professor David Taylor outlines his comprehensive, and well-spread, financial conflicts of interest:

003
Even though not a doctor, after I wrote to him, Prof David Taylor submitted his declarations to whopaysthisdoctor.com . We should commend this openness, as here Professor Taylor is a leading example of openness. It is important however that we consider that in “offering” “education”  Professor Taylor has significant financial under-writing. Professor Taylor has had a significant role in the development of UK-wide guidelines on prescribing in mental health.

Three years back: On the 17th May 2011 I wrote to NHS Forth Valley to say that I found that the link to the “Hospitality Register” was non-functioning. It took two years of polite inquiry for NHS Forth Valley to finally confirm that as an NHS Board it had NO register of interests for ALL staff. I was later to discover (through Freedom of Information requests) that this was a pattern spread across ALL twenty-two of NHS Boards in Scotland:

007
Eleven years back: in circular HDL(2003) 62 The Scottish Government stated that “Chief Executives are asked to establish a register of interest for ALL NHS employees and primary care contractors”: 

027



This year: The Director of Medical Education for NHS Forth Valley, said (25 February 2014) “Traditionally we have not registered the various meetings on the list as it was not required of us”. 

I will post some recent examples of sponsored education involving NHS Forth Valley employees. I do so without wishing to focus on any individual. It is important that what I present is understood only as part of a wider pattern.

It may be my error, but I cannot find any declarations made, by those potentially involved in any NHS Forth Valley Register. I wrote to the General Manager of NHS Forth Valley on the 20th March 2014, where I included ALL the following examples of employees involved in what would appear to be sponsored meetings.

[the coloured highlights in the following promotions are mine (they are only part of my much wider effort to bring transparency). My endeavour is not to single any individual out.]

[I recognise that the sample I present (based on my much wider pinterest page) is simply the promotions for “education” which have come my way.]

023


024


022 

 020

Patterns appear at all levels and not just “local”. For the governance of conflicts of interest, at a UK level, we follow the General Medical Council.  At annual appraisal and at five-yearly revalidation all doctors are asked to sign a probity section where each individual doctor confirms (or not) the following (this screenshot is from my recent Revalidation):

012
Before closing: the following example of an “educational” “CPD” event reveals a pattern that does not just involve those employed by the NHS:

021
The pattern is broad. I have no doubt. I recently debated with Professor Clive Ballard at a Royal College of Psychiatry Conference in Durham. I suggested to the organisers, well in advance of the conference, that all those involved might consider that they declared any financial interests in the programme. The organisers agreed that this was a good suggestion. As it turned out I was the only one to declare that I had no financial interests.

011
Professor Ballard chose not to reveal in the RCPsych programme, or in his presentation, any potential financial conflicts of interest.

Another speaker at this RCPsych Conference was Prof Allan Young. Like Professor David Taylor he had given hearty support to the promotion of Asenapine (my NHS email in-box was frequent witness to all of the promotions).

At the RCPsych conference, where I was a fellow speaker, Professor Allan Young started out by mocking any need for transparency: “for those of you who watch panorama, I do not give my consent for you to film this”. Professor Allan Young then presented his “Conflict of Interest Statement”. He did not talk his interests through (unlike the rest of his presentation) and my image is thus blurry (and “photo-shopped” to my best ability). Professor Allan Young presented his multiple financial interests in a blink of an eye but also fortunately in a camera click.

In my camera click, I resisted Professor Allan Young’s wishes. Light is important to all patterns.

015
Following my advocacy, NHS Forth Valley, would seem to be the only NHS Board, out of Scotland’s twenty-two NHS Boards to have an open access register for all employees.

From the evidence I have gathered it seems clear to me that Scottish Health Boards continue to fall very far short of complying with HDL 62. Yet this guidance delivered to ALL NHS Board Chief Executives is now 11 years old!

I am not legally minded. Senior Health Board Managers in Scotland are signing off annual Appraisals and five yearly Revalidation that staff are individually following their employers Guidance (including Scottish Government HDL 62 guidance: guidance issued to all Chief Executives in 2003) . The GMC are clear on what is expected regarding “probity”

It is for this reason that I submitted a petition to the Scottish Parliament suggesting that they might consider a Sunshine Act. Other countries have instituted such legislation. Like John Betjeman, I do not welcome bureaucracy, however a central, access to all register, enshrined-in-law, should be neither difficult nor burdensome to implement."

“Believe me, that is not the way to get things done” Peter J Gordon, Hole Ousia [Reblog]


Wednesday, 19 November 2014

Re: 'Why are we failing young patients with ADHD?' Iain McClure, BMJ Response

Views & Reviews Personal View

Why are we failing young patients with ADHD?
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6082 (Published 13 October 2014) Cite this as: BMJ 2014;349:g608

Re: Why are we failing young patients with ADHD?

16 November 2014: Iain McClure, consultant child and adolescent psychiatrist,NHS Lothian Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK 

"Simon Bowers correctly states that few geographical areas offer clinical pathways that include holistic interventions for ADHD (1). He argues for ‘a definitive diagnosis’ and ‘evidence based treatments’ from the outset, but the reality is that ADHD is such a confused, over-simplistic and, consequently, over-diagnosed disorder, that it cannot deliver the certainty that health managers understandably expect on behalf of tax payers.

Instead, the failure of ADHD research to deliver a valid and reliable concept of impairment within the condition, means that, all too often, children diagnosed with ADHD are prescribed stimulant medication from the outset, whether their condition is severe, moderate or mild (2,3). In all likelihood, these patients, once prescribed stimulant medication, will continue to take it throughout their primary and early secondary school years, with increasing numbers remaining on it into adulthood. Because of the increasing pressure on doctors in community paediatric and child psychiatric clinics, many of these patients will not receive a 'drug holiday' from this medication throughout these years, despite the advice of guidelines (2). This situation contrasts starkly with mainstream general adult psychiatric practice, regarding antidepressants or antipsychotics, in which doctors expect to at least attempt a withdrawal of such medications, once the patient has remained clinically well for several months.
One of the anomalies of ADHD compared to other psychiatric conditions, is that it appears to offer no recovery concept, except stabilisation on medication. Why is this? Usually, such a scenario only arises in those child patients who have life-threatening conditions, such as asthma, epilepsy or cystic fibrosis. Yet we know that ADHD is not life-threatening and that there is no evidence that stimulants reduce the long term problems associated with the severe form of the condition, let alone the milder forms (2,3).
The current, apparently inevitable trajectory of ADHD diagnosis and consequent long-term medication for moderate, or even mild cases, accretes associated issues, such as disability and carer benefits, which gain supertanker momentum. Given the pressure which doctors are under to accommodate this powerful system, services fail to develop the alternative strategies which Simon Bowers is asking for. Even if Clinical Commissioning Groups do have the transformational clout to look at this situation with ‘a fresh perspective and a determination to do things differently’ (1), are there sufficient numbers of qualified (and, more importantly, motivated) clinicians who can run psychological group treatment programmes (which is what NICE recommends should be the first line treatment for moderate ADHD(4))?
To really tackle this problem, we need to completely dismantle the ADHD concept and generate something which more accurately describes children and adolescents, their thoughts, feelings and behaviour, the families they live in and the social systems around them, all within a nurture, as opposed to a disorder, concept.
At the very least, clinicians, health managers and guideline bodies such as NICE and SIGN should challenge the ADHD industry (academic and pharmacological) to produce a disease concept which accurately describes levels of severity (which, for example, autism science has achieved). Only if such evidence emerges, will health and local authority managers be able to attempt to develop multi-agency pathways which accurately meet the needs of these vulnerable children and young people.
However, given that the drug industry for ADHD in the USA alone was worth $9 billion annually in 2012 (and continues to increase) (5) any such progress seems a distant prospect. Perhaps the best way to get full value out of the Liverpool pound is to withhold it."
References:
1. Why are we failing young patients with ADHD? Bowers, S. BMJ 2014;349:g6082
2. Prescribing methylphenidate for moderate ADHD. McClure, I. BMJ 2013;347:f6216
3. Attention-deficit/hyperactivity disorder: are we helping or harming? Thomas, R, Mitchell, GK, Batstra, L. BMJ 2013;347:f6172
4. National Institute for Health and Care Excellence. attention deficit hyperactivity disorder. QS39. 2013. http://publications.nice.org.uk/attention-deficit-hyperactivitydisorder-....
Competing interests: I am Chair of the review of the SIGN guideline on Autism Spectrum Disorder and a member of SIGN's Guideline Programme Advisory Group.


Monday, 3 November 2014

Review of 'The Bitterest Pills: The Troubling Story of Antipsychotic Drugs' Joanna Moncrieff in BJPsych by Duncan Double

'The Bitterest Pills: The Troubling Story of Antipsychotic Drugs' By Joanna Moncrieff, reviewed by Dr Duncan Double (@DBDouble), Consultant psychiatrist and honorary senior lecturer, Norfolk & Suffolk NHS Foundation Trust and University of East Anglia, in BJP November 2014 205:414:

"This is an important book. You might think I would say that as a member of the Critical Psychiatry Network, like the author, Joanna Moncrieff, senior clinical lecturer at University College London. However, I do think her critique has a sound academic grounding and engages with public concerns about antipsychotic medication.  

The book describes the extent to which the prescription of antipsychotics is marketing-based rather than evidence-based.  Chlorpromazine, of course, was the first drug seen as having a specific role in the treatment of mental illness. Moncrieff, instead, emphasises the non-specific nature of antipsychotic effects, which she frames by promoting a drug-centred rather than disease-centred model of their action. Nonetheless, she says that antipsychotics can ‘help individuals gain relief from intense and intrusive psychotic experiences or destructive emotional states’ (p. 18). 

By this she means more than their placebo effect and believes they can be of value as emotional suppressants. I would encourage you not to dismiss her approach as unbalanced. Despite what may seem like niggling overstatement at some points, she does present a genuine argument, with which I think it is important to engage.  She describes the wish-fulfilling nature of the dopamine theory of schizophrenia. She also makes a stronger case than even I was aware of for ventricular enlargement in schizophrenia being a drug-induced phenomenon. (bolding is mine)

Historically, as she points out, there has been denial in psychiatry about traditional antipsychotics causing tardive dyskinesia and atypical antipsychotics producing the metabolic syndrome. Her summary critique of the early intervention approach also seems to me to be one of the best available.  

I am sure this book will be too sceptical for most psychiatrists.  It may seem to undermine psychiatry’s cultural system.  Personally, I think psychiatry needs to face up to the truth about the psycho-pharmacological revolution, rather than continuing to rely on its aura of factuality.  Even the past editor of this Journal Professor Peter Tyrer agrees we should call an end to the post-chlorpromazine era. I hope Jo’s book makes a significant contribution to this debate."