Thursday, 30 April 2015

“All in the past”: well, no. #HoleOusia Dr Peter J Gordon [reblog]

Dr Peter J Gordon: “All in the past”: well, no.
on Hole Ousia website, 30 April 2015:

All in the past from omphalos

"Seven years ago this Editorial was published in the BMJ:


Eleven years ago, all NHS Chief Executives in Scotland were asked in to implement and govern Scottish Government circular HDL 62. This has not happened.

The General Medical Council published nine years ago:  “Good Medical Practice”, which makes very clear:

Annexe A, GMC 

General Medical Council on conflicts of interest from omphalos

Seven years ago the Royal College of Psychiatrists issued its own guidance, CR148:

CR148 says (3) 

Given these multiple levels of failing in governance, and in the pursuit of scientific objectivity, I have petitioned the Scottish Government to consider implementing a Sunshine Act. The research behind this can be accessed here.

I am employed as an NHS psychiatrist and have been an NHS Consultant for 13 years.
Over this time, the key opinion leaders in UK psychiatry (though I have never met) have become known to me.

Continuing Medical Education invites (generally “CME-accredited”) come to my NHS e-mail address on a weekly basis.

As an NHS employee I have had regular invites to attend “CME-accredited” conferences that include educational talks by distinguished speakers such as:

  • Professor Allan Young
  • Professor Peter Passmore
  • Professor Guy Goodwin
  • Professor Philip J Cowen
  • Professor David Nutt
  • Professor J Chick
  • Professor David Taylor (pharmacist)
  • Professor Clive Ballard
  • Professor Nick Fox
It is the case that (in 2015) we still have no way of knowing how much may be paid to any individual to educate professionals like myself

The ABPI “central platform”, which will be operational next year, allows individuals to “opt out” of revealing any payments.

Dr McCartney has long argued that the medical profession should take the lead on transparency. I agree.


The Royal College of Psychiatrists guidance CR148 has not been followed since it was introduced seven years ago. The updated system (following my dogged persistence) still fails to require details of monetary exchange or for specific dates of (any such) payments.
The USA have introduced a Sunshine Act and so in recent years, drug companies have started releasing details of the payments they make to doctors and other health professionals for promotional talks, research and consulting:


Over a decade ago, I noted this letter of reply by Professor Philip J Cowen. A reply that troubled me.

 Cowen, P J - Constructionism 24-5-2011

Professor Philip J Cowen

A straightforward internet search would indicate that Professor Cowen has followed extant guidance regarding transparency. Here follows some of the material on Professor Cowen to be found in the public domain:

Cowen, P. J,CINP, 2016

Cowen, P J - 3-3-2014

Cowen, P J - 17-11-2014
Cowen, P J - 19-5-2011

Cowen, P J - 2011

2011, RCSPsych Int Congress

Cowen, P J - 2014 b

Cowen, P J - 2014

Cowen, P J - 2015

Cowen, P J - April 2014

Cowen, P J - April, 2012

Cowen, P J - Aug 2010

Cowen, P J - Aug 2013

Cowen, P J - Dec 2012

Cowen, P J - ECNP

Cowen, P J - Jan 2015

Cowen, P J - May 2012

Cowen, P J - Nov 2012

Cowen, P J - Nov 2012b

Cowen, P J - Nov 2013

Soft rebuttal, 2001

Monday, 27 April 2015

my tweets to @PsychiatrySHO aka Alex Langford re his #BMJ Response 'Healy does a disservice to psychiatrists'

25 April 2015 
Alexander E Langford
Core Trainee in Psychiatry
South London and the Maudsley NHS Foundation Trust

in response to Dr David Healy's Editorial 'Serotonin and depression' 21 April 2015
BMJ 2015;350:h1771

My tweets this morning to Alex Langford @PsychiatrySHO:

Saturday, 25 April 2015

'Dodging Abilify' by Johanna Ryan @RxISK [reblog]

'Dodging Abilify' by Johanna Ryan on RxISK website:

"Editorial Note:  This post is by Johanna Ryan, who has a unique ability to capture the American Nightmare 

The best-selling drug in the United States isn’t a blood pressure pill, a painkiller or even an antidepressant.  It’s Abilify, an antipsychotic agent with $6.3 billion in 2013 sales.  Granted, Abilify isn’t the most prescribed pill, but its #1 status is sealed by popularity and high price: the current retail price of a 30-day supply is now a whopping $900, and it’s 23rd in sheer numbers of prescriptions.  In 2011 the Medicaid program in my home state of Illinois spent $53.6 million on Abilify for its poorest citizens, more than it spent on any other drug.
I’m not the first to ask, what the hell is going on here?  However, my interest in Abilify is personal:  Wherever I go in the healthcare system, people have been urging me to take it, and even suggesting there’s something irrational about my reluctance.

Phase 1: Dodging bipolar disorder

A brief word about my situation:  I’ve been treated for depression, at times severe, since 1975.  Over the years I’ve been unable to work for brief periods, fairly miserable but officially “functional” more often.  Still, I’ve never once experienced psychotic symptoms.  No voices, no visions, no strange beliefs or fears, and no “manic” periods of wild activity and grandiose plans.  Back in the 1980’s I was hospitalized a few times as actively suicidal, and was once given antipsychotics – but only for the first week or so.  I didn’t like them then; I felt more passive than truly calm, and unable to complete an intelligent thought.
Having watched the rollout of “new and improved” antipsychotics in the 1990’s that turned out to have just as many problems as the old ones, I still don’t like them.  However, it wasn’t until 2006 that I really got skeptical about psychiatric drugs in general.  Despite a long trail of meds that had done me no good, stopped working or had miserable side effects, I was always willing to try the next milestone in the march of science – unless it was an antipsychotic.

Ten years ago, the new antipsychotics were easy to refuse.  The theory behind giving them to people like me was that repeatedly depressed people might have “bipolar disorder type II”, a mood disorder without actual mania, and should take these drugs as “mood stabilizers.”  My longtime psychiatrist, Dr. A, knew me too well to really believe I was bipolar; he told me he thought it made little difference what label he put on my depression since none of them could be verified.  Still, he thought these drugs well worth a try.  “They’re not necessarily antipsychotics,” he said. “That’s just a label, they’re used for lots of things.”  “I know,” I replied, “but they’re still neuroleptics. I want to hang on to all the brain function I can.

“Oh, come on,” he coaxed.  “We’re talking about little baby doses here, just a fraction what they give people for schizophrenia.”  That sounded somewhat reassuring – but I still said no. (Today I’m glad I didn’t listen to that particular sales pitch, as I’ll explain later.)

Back in those days, I could tell a family doctor, OB/GYN or nurse that Dr. A wanted me to take antipsychotics, and they’d look bewildered.  Even flinch a bit.  “But you’re not… I mean …”  “Right,” I’d say. “Not psychotic.  And unless and until I start hearing voices, I’m not touching that stuff.  Even if I do start hearing voices, I’m not taking it a day longer than I have to.”  They all thought that made sense. ..."

Read complete RxISK post

image from RxISK post

Thursday, 23 April 2015

'Serotonin and depression': Dr David Healy in the #BMJ

'Serotonin and depression': Dr David Healy -

[and on Mad in America as 'So Long, and Thanks for All the Serotonin']

Editorial; BMJ 2015;350:h1771; Published 21 April 2015

"The marketing of a myth

The serotonin reuptake inhibiting (SSRI) group of drugs came on stream in the late 1980s, nearly two decades after first being mooted. The delay centred on finding an indication. They did not have hoped for lucrative antihypertensive or antiobesity profiles. A 1960s idea that serotonin concentrations might be lowered in depression1 had been rejected,2 and in clinical trials the SSRIs lost out to the older tricyclic antidepressants as a treatment for severe depression (melancholia).3 4 5

When concerns emerged about tranquilliser dependence in the early 1980s, an attempt was made to supplant benzodiazepines with a serotonergic drug, buspirone, marketed as a non-dependence producing anxiolytic. This flopped.6 The lessons seemed to be that patients expected tranquillisers to have an immediate effect and doctors expected them to produce dependence. It was not possible to detoxify the tranquilliser brand.

Instead, drug companies marketed SSRIs for depression, even though they were weaker than older tricyclic antidepressants, and sold the idea that depression was the deeper illness behind the superficial manifestations of anxiety. The approach was an astonishing success, central to which was the notion that SSRIs restored serotonin levels to normal, a notion that later transmuted into the idea that they remedied a chemical imbalance. The tricyclics did not have a comparable narrative.

Serotonin myth

In the 1990s, no academic could sell a message about lowered serotonin. There was no correlation between serotonin reuptake inhibiting potency and antidepressant efficacy. No one knew if SSRIs raised or lowered serotonin levels; they still don’t know. There was no evidence that treatment corrected anything.7

The role of persuading people to restore their serotonin levels to “normal” fell to the newly obligatory patient representatives and patient groups. The lowered serotonin story took root in the public domain rather than in psychopharmacology. This public serotonin was like Freud’s notion of libido—vague, amorphous, and incapable of exploration—a piece of biobabble.8 If researchers used this language it was in the form of a symbol referring to some physiological abnormality that most still presume will be found to underpin melancholia—although not necessarily primary care “depression.” 

The myth co-opted the complementary health market. Materials from this source routinely encourage people to eat foods or engage in activities that will enhance their serotonin levels and in so doing they confirm the validity of using an antidepressant.9 The myth co-opts psychologists and others, who for instance attempt to explain the evolutionary importance of depression in terms of the function of the serotonin system.10 Journals and publishers take books and articles expounding such theories because of a misconception that lowered serotonin levels in depression are an established fact, and in so doing they sell antidepressants.

Above all the myth co-opted doctors and patients. For doctors it provided an easy short hand for communication with patients. For patients, the idea of correcting an abnormality has a moral force that can be expected to overcome the scruples some might have had about taking a tranquilliser, especially when packaged in the appealing form that distress is not a weakness. ..."

“PULSE Live is heading to Scotland”: the Corn Exchange: Hole Ousia post, Dr Peter J Gordon (reblog)

“PULSE Live is heading to Scotland”: the Corn Exchange:  Dr Peter J Gordon on Hole Ousia website:

"My wife is a GP working in NHS Scotland and was recently invited to the “PULSE LIVE 2015″ educational conference to be held in Edinburgh on the 19 May 2015:

Pulse Live 1 

This educational conference is to be held in Edinburgh’s Italianate and historical CORN EXCHANGE. General Practitioners can register for a free place and 7 CPD hours are accredited:

Pulse Live 2 

In my earlier career I trained as a Landscape Architect at Edinburgh University and was awarded the Scottish Chapter prize. This will explain to you why old buildings and designed landscapes interest me. The Corn Exchange was where traders brought grain to  for sale. It was a place of barter: where goods were exchanged for money:

Former corn exchange 

With this in mind it is worth looking at the PULSE LIVE 2015 programme and noting that a significant number of the educational talks are sponsored by the pharmaceutical industry or other commercial enterprises. The speakers are mostly from NHS Scotland and one assumes they will receive honoraria:

Dr Douglas Elder, Bayer HealthCare, 2015 Dr Paul Newman, Johnson & Johnson, 2015 Dr Richard Watson, Lundbeck, 2015 Dr Tom Fardon, Pfizer, 2015  LUTS, 2015, Pulse Live, Astellas 

My interest in this area relates to my wish to consider the ethics of medical practice. Specifically my interest is in public transparency of any financial transactions between healthcare workers and academics and wider commerce. I should make it very clear: I understand that conflicts of interest are part of life. 

Over a few years I have collected the invites to NHS doctors to attend pharmaceutical sponsored education. These invites are collected here and demonstrate that the financial sponsorship, as included as part of PULSE Live 2015, is generally the norm. Dr McCartney has considered this in her BMJ Column of last week: Forever indebted to pharma—doctors must take control of our own education:


My petition to the Scottish Government for A Sunshine Act is a request for transparency surrounding financial payments in healthcare and medical education to be routine. I have suggested that Scotland might lead the way on this for the rest of the UK. America and France have introduced a Sunshine Act.

Open and transparent from omphalos on Vimeo. NHS Scotland has miserably failed to follow Scottish Government guidance HDL 62. This Government Circular was issued to all NHS Scotland Chief Executives over a decade ago. The Scottish Government have, since my petition, now accepted widespread failure across NHS Scotland to follow HDL 62.


The Cabinet Secretary for Health, Wellbeing and Sport, Shona Robison MSP, wrote recently to the Convener of the Scottish Parliament Petitions Committee. 

Shona Robison, 24-4-2015 

The Cabinet Secretary for Health, Wellbeing and Sport, asks for a “broader view” on this matter that the Scottish Government agree is “important”. The Cabinet Minister will be attending PULSE Live 2015 for the “Big Interview”:

Pulse Live, Cabinet Minister for Health, May 2015 

Perhaps the Cabinet Secretary for Health, Wellbeing and Sport, will look upwards to the roof of the Corn Exchange as it is celebrated for its “massive single-span”. Sponsored Medical Education also celebrates a massive span in Scotland. Please do not be fooled into thinking this, like the Corn Exchange and bartering it once housed, is a thing of the past. So go on, if you dare, be like me, and shout this from the roof-top!"

Former corn exchange