Monday, 30 March 2015

Dr David Healy: 'Winging it: Antidepressants and Plane Crashes' [reblog]


 'Winging it: Antidepressants and Plane Crashes' by Dr David Healy, 30 March 2015:

"The crash last week of the Germanwings plane has shocked many.  In view of the apparent mental health record of the co-pilot Andreas Lubitz, questions have been asked about the screening policies of airlines.  The focus has generally been on the conditions pilots may have or the arguments they might be having with partners or other situational factors that might make them unstable.

Even when the issue of the medication a pilot may be taking is raised, as an article by Erica Goode in the New York Times makes clear it is in the context of policies that permit pilots to continue on drugs like antidepressants to ensure any underlying conditions are effectively treated.

Side-Effective 

Clearly if a drug is effective in clearing up an underlying condition, its use should make the pilot – or driver of a coach carrying 50 or more passengers – safer.  But fewer treatments in medicine are effective in this sense than people might think and even when effective they come with effects that need to be balanced against the likely effects of the underlying condition.

Doxycyline, for instance, a widely used medicine for acne and for malaria prophylaxis, can be very effective for acne.  But doxycycline can also make someone depressed, suicidal and homicidal, while acne doesn’t do this.

Other antibiotics like Levaquin and Cipro can cause a range of serious and enduring problems including psychosis but are ordinarily given for problems that are unlikely to compromise a pilot’s ability to fly and keep her passengers safe.

Antidepressant Effects

So what about depression?  The risks of suicide or homicide from mild to moderate depression or anxiety are almost nil.  Think of it this way – what we call depression today in nine cases out of ten was called anxiety 30 years ago before the development of the SSRIs and anxiety was not thought of as a significant risk factor for suicide or homicide.

Difficulties with a partner or at work can lead to precipitate action including suicide or homicide.  They can also lead to anxiety or depression but the anxiety or depression linked to these events don’t for the most part cause problems except in so far as sleeplessness on the one side or a sedative drug on the other might cause an accident.

Whatever the risks of suicide or homicide linked to such anxiety or depressive states might be, in clinical trials antidepressants close to double them – and not just in younger adults. They do so by causing psychosis, or by producing an agitation laced with suicidal or homicidal thoughts, or by producing an almost lobotomized state in which people will do things they would ordinarily never do, or by increasing blood alcohol levels if the person has had a drink.

GSK data suggest these drugs appear to make someone more likely rather than less likely to “act out” if they have just had a partner break up with them.  See Kraus – Clinical features of patients with treatment-emergent suicidal behavior following Paroxetine.

All of this has been relatively well known for decades.  We could have made things much safer by discussing the changes treatment can trigger openly much earlier and permitting patients and doctors to identify problems and find solutions – such as switching to a drug of a different class.  Doctors and patients have been left flying by the seat of their pants.

The Debate

There are likely to be a number of features to the current debate.

First an impression will be created that we know more about these drugs than we in fact do.  

We know almost nothing about what antidepressants actually do – we still don’t know what they do to serotonin.

Rather than being effective like an antibiotic, these drugs have effects – as alcohol does. Their primary effect is to emotionally numb. Patients on them walk a tightrope as to whether this emotional effect is going to be beneficial or disastrous.

We know even less about other drugs Lubitz might have been on such as mood-stabilizers.  These too can produce suicidality and homicidality but they have a different signature to that of antidepressants.  The trouble is that, unlike the case of the SSRIs, no doctor giving any patient a mood-stabilizer can tell them what to watch out for or what the timeframe of problems is likely to be.

Lubitz has been widely reported as having vision problems – see  Mail on Sunday. Antidepresants cause visual problems – see RxISK.  But there is little known about these problems.

Second there are a lot of powerful interests at stake.

Some of these will think nothing of playing the personality card in the case of Lubitz to create the impression this was all about his instability rather than an instability in him created by treatment.

Third these powerful interests employ the best public relations on the planet.

These companies will in a variety of ways play the card that anyone suggesting treatment may have been part of what went wrong are just conspiracy theorists.

Fourth efforts to manage the problem will be portrayed as effective.  

We will hear that the Federal Aviation Authority in the US only permits pilots to fly on a selected number of antidepressants when they have been stable on treatment for six months.  Sounds good.  But no mention of the problems that happen on withdrawal – which are as great as those that happen on starting.  See Antidepressant Withdrawal: A Prozac Story – on RxISK.  Prozac is one of the selected antidepressants.

Once treated with a drug, a pilot is never the same again.  Even if the underlying condition clears, he may not be able to stop.  The risks are not eliminated.  The only way to manage these risks is to have a close relationship between the pilot and her doctor in which the doctor is fully informed as to what the risks are – a doctor who acts like a pilot in the sense that she doesn’t take risks that will bring her down along with her pilot–patient.

Let them Burn

In lectures for several years  – see Professional Suicide, I have compared the roles of doctors and pilots saying that we are all safer flying than we are in the hands of our doctors because the pilot knows if the system isn’t safe and you die, she will also, whereas doctors can always and routinely do blame your condition or your circumstances.

This idea has now crashed into Andreas Lubitz and his doctors.  We are all wondering about Lubitz and what motivated him.  What about the doctors who may have unintentionally primed him?

At the moment it is difficult to see Lubitz as a victim but he may be.  His doctors may also be victims.  They may have joined a string of doctors who agonize over horrific events they are party to.

Treatment may not have precipitated what happened in this case but there are many people in the pharmaceutical industry who have known for a long time that something like this can happen on their medication and they have done nothing to put in place systems to manage these risks or to dismantle the system that gives rise to risks like this at a much greater rate than we should have to tolerate.

That corporations might do this is not a conspiracy theory. In the famous Ford Pinto case, a Ford executive made aware of risks that their car would lead to a regular number of drivers and passengers being incinerated each year – a problem that could have been inexpensively put right – famously wrote


The powers that be have been winging it for decades."

Sunday, 29 March 2015

Reblog: 'Cash for dementia' by Dr Peter J Gordon on Hole Ousia

'Cash for dementia' by Dr Peter J Gordon on Hole Ousia website:

"Today a friend of mine sent me a copy of this article by Dr Gavin Francis:

LRB - cash for diagnoses - Gavin Francis

Professor June Andrews of the Dementia Development Centre gave this published reply:

LRB - cash for diagnoses - June Andrews June Andrews

Dr Francis replied in turn:

LRB - cash for diagnoses - reply to June Andrews

More than two years ago I shared my concerns with Professor June Andrews about the potential harms associated with the early diagnosis of dementia:

June Andrews (7)

Professor June Andrews has remained consistent over the years in advocating the early diagnosis of dementia. I have long advocated a timely approach to the diagnosis of dementia. The debate between timely and early diagnosis is summarised here. A timely approach was recently enshrined in the Glasgow Declaration which has now been signed by 38 organisations across Europe.

dementia-services copy

Professor Andrews states that a failure to diagnose as early as possible should result in legal action. I am extremely disappointed that such an influential individual appears to fail to grasp the complexity of this area and advocates the practice of defensive medicine.

It is to Dr Francis’ credit that he has replied with such restraint."

ethics1 (1)


Friday, 27 March 2015

Reblog: All speaking at today’s Old Age Faculty Annual Meeting will have submitted a DOI; 26 March 2015

Dr Peter J Gordon: 'All speaking at today’s Old Age Faculty Annual Meeting will have submitted a DOI', 26 March 2015, Hole Ousia website:

"From: Vanessa Cameron
Sent: 26 March 2015 17:22
Subject: RE: Royal College of Psychiatrists and transparency: “Criticisms of yesteryear”?


Dear Dr. Gordon,
Thank you for sending this which I did see this morning – I enclose the College’s response via twitter:


 
@rcpsych is committed to our COI policy. All speaking at today’s Old Age Fac’ Annual Meeting will have submitted a DOI

Yours sincerely  
Vanessa Cameron

Vanessa Cameron
Chief Executive
Royal College of Psychiatrists


Dear Ms Cameron,
Thank you for this. I am not on twitter (or any form of social media) and my communications to the Royal College of Psychiatrists have not been through social media.


I look forward to a reply from you by e-mail or letter with complete declarations of financial declarations of speakers, and those involved, with this RCPsych conference. I will share these on Hole Ousia.

Yours sincerely
Dr Peter J Gordon

GMC number 3468861"


Reblog: 'Royal College of Psychiatrists and transparency: “Criticisms of yesteryear”?' Dr Peter J Gordon

'Royal College of Psychiatrists and transparency: “Criticisms of yesteryear”?' Dr Peter J Gordon, Hole Ousia website, 26 March 2015:

"For several years now I have written to the Royal College of Psychiatrists regarding an apparent lack of meaningful transparency regarding financial conflicts of interests in our profession.

A recent communication with the Royal College included discussion of the following Conference being held this week in Scotland:

Old Age March 2015 RCPsych
I confirmed to the Treasurer of the Royal College of Psychiatrists my wish to take up the offer to be sent all Declarations of interest of those speaking and involved in this CPD approved Conference:

Nick Craddock on declarations March 2015
The current Chair of the RCPsych Ethics Committee is attending this Old Age Psychiatry Annual Scientific Meeting and stated:

Chair of RCPsych Ethics Committee
Operational Guidance issued by the Royal College of Psychiatrists asks that the following three principles should be followed:

Principles of RCPsych
The Royal College of Psychiatrists newsletter for this month comments on the Association of the British Pharmaceutical Industry register (or Central Platform as they have termed it) which will not be available till next year. This register, despite what this newsletter says, will have no “force” as healthcare workers can opt-out of revealing any financial payments:

RCPsych March 2015
It would seem very clear to me that what is happening, or perhaps not happening in March 2015, should not be labelled as that of “yesteryear”."

Sunday, 22 March 2015

Reblog: 'Do we care enough about consent?' Dr Peter J Gordon, Hole Ousia

'Do we care enough about consent?' Dr Peter J Gordon, Hole Ousia:

"This leaflet is widely available to patients in NHS Scotland including in the waiting room outside my consulting room: 

039

Its first page defines consent as follows:

038

This is the front page of the current BMJ:

021

It is reporting on a legal ruling which has implications for consent as summarised by the editor:

051052 053 054

Previously Sokol has said:

013

I have had a longstanding interest in consent:

015

Consideration of patient consent goes back to the earliest days of the NHS (and indeed before):

032

I have previously highlighted how this difficult area becomes even more complex when we are considering cognitive screening:

014

Scotland led the way with an incentivised target-based approach to the “early diagnosis” of dementia. The following is from one of the earliest expert meetings:

First Dementia Strategy Meeting

A few years later the Scottish Government were sharing widely league tables:

002

The Scottish Government commended its own approach to the Westminster Government:

How to improvegeoff-huggins4 Geoff Huggins3

It was this robust approach that led me to consider whether the consent to assessment of the individual patient might be significantly affected by an external target. It was at this stage I contacted the National Clinical Leads for dementia, specifically highlighting my concerns about consent:

Dementia Leads1

The Scottish Lead for Dementia replied:

Dementia Leads2

I was delighted to attend this Conference in Glasgow which culminated in the signing of a rights-based approach to dementia:

034044

At this Conference, the Chief Executive of the Mental Welfare Commission gave an address. Mr Colin McKay reminded us that for any individual deemed to lack capacity certain principles should apply. This includes having one’s own wishes listened to:

020


The previous Chief Executive of the Mental Welfare Commission offered his personal view on consent to examination. For many reasons I believe that cognitive screening is a very different activity to measuring blood pressure:
 
056

I have also been in conversation with parliamentarians regarding consent to cognitive screening. In my letter to Dr Simpson, MSP, I highlighted the following points:

  • my concerns are specifically about obtaining consent to cognitive screening
  • Cognitive screening does not fulfill World Health Organisation criteria (Wilson & Jungner)
  • the UK National Screening Committee do not advise screening for cognitive impairment

Richard Simpson2

This is the view of the former Cabinet Minister for Health & Wellbeing:

At liberty

I have also asked the UK’s leading Dementia charities about consent:

042

I have recently written to Alzheimer Scotland about this current campaign. Disappointingly this appears to have back-tracked from the Glasgow Declaration and is advocating early rather than timely diagnosis. The “difficult conversation” as suggested by Alzheimer Scotland appears to me to trivialize consent:

033

I have also had a number of “difficult conversations” when trying to raise issues of consent:

Dr Brian Robson

One of the many reasons why this matters is that cognitive screening is not risk-free. 

046047

Off-label anti-psychotic prescribing has increased year-on-year in the elderly across Scotland.
It is my view that those promoting improvement methodologies in NHS Scotland are currently not taking consent sufficiently seriously. It appears that I am not alone in having found these conversations “difficult”:

061

The following post was about improvement work in the elderly on the Ayrshire Health blog. The full post and all responses to it can be read here:

Flying without wings1

I submitted a reply which outlined my considerations about obtaining consent for cognitive screening. In response to my considerations, the Associate Nurse Director of Mental Health Services in NHS Ayrshire and Arran and Chair of the Mental Health Nursing Forum Scotland, appeared to remain unsure of the basis of my concerns:

Flying without wings2

Professor June Andrews, Director of the Dementia Services Development Centre offered the following 
 advice:

June Andrews3

A service user shared my concerns about patient consent and raised the matter with the Ethics Committee of the Royal College of Psychiatrists:    

John Sawkins

Over a decade ago, NHS Scotland published this Expert Group report:

Adding life to years, 2002 aAdding life to years, 2002 cAgeism in NHS Scotlandc

This blog post asks if we care enough about consent? My view is that the principle of patient consent should be a fundamental right for all ages. It is the case that consent is a complex area but this is not a good enough reason for marginalising it. I would argue strongly that wider discussion particularly involving all of our elders is long overdue."