The sense in saying antidepressants don't work

According to a Times article, Sir Simon Wessely, President-elect of the Royal College of Psychiatrists, thinks it is "nonsense to say that antidepressants do not work". I presume he's saying that antidepressants are more than placebos. He may know more than I do, but he doesn't seem to think that the small effect size in clinical trials could be due to placebo amplification due to unblinding (eg. see previous post).

I guess he has to believe this as head of the Royal College of Psychiatrists. My scepticism means I'm never going to fulfill this role! It's alright for Simon to say that he doesn't really buy parents promoting the idea that their children who get into Oxford are mildly autistic. And, that modern services couldn't be less well designed to join up physical and mental health care. But it's beyond the pale to suggest that psychotropic medication is not effective.

The benefit-to-harm ratio of antidepressants

A Lancet Psychiatry article attacks Peter Gøtzsche (who I have mentioned in a previous post) for saying that antidepressants do more harm than good. Although his Guardian article has this headline, in fact what he wrote was "the way we currently use psychiatric drugs is causing more harm than good" [my emphasis]. He doesn't seem to be advocating not using antidepressants at all, but "much less, for shorter periods of time, and always with a plan for tapering off, to prevent people from being medicated for the rest of their lives".

As I commented in my previous post about Gøtzsche, the problem is that attacking him in this way deflects from the validity of what he is saying. I wish mainstream psychiatry would engage more with me. I do know it is important to avoid overstatement (see previous post). The Lancet Psychiatry article emphasises the effect size found in antidepressant trials. What it doesn't discuss is whether this finding could be explained by placebo amplification due to unblinding in clinical trials (eg. see previous post). Nor does it discuss the bias in the literature introduced through selective publication. These days this is because data submitted by the drug companies to the regulatory authorities is not always examined completely. Previously, with older trials, this was because of what was called the 'file drawer problem' (see further information) in that negative trials did not always get published. This may well have affected the amitriptyline data that the Lancet Psychiatry article cites.

As I said in a comment on a previous post, it's important not to get too hung up by the size of effect in clinical trials. Maybe I'm too sceptical, but the finding that non-psychiatric drugs have similar effect sizes in clinical trials does not imply that psychiatric drugs are effective, but that medical as well as psychiatric clinical trials are subject to the same biases of unblinding (see previous post).

The authors of the article speculate about the reasons for doctors questioning the effectiveness of antidepressants, suggesting it is the anti-psychological bias of doctors that makes them want to believe that there can't be a physical treatment that could possibly be effective for mental illness. So, they try to turn the tables on critics by suggesting it's the critics not them that are stigmatising mental illness. They feel insulted by the critique but it is important to be open to argument and not prejudiced.

Finnish psychologist sacked after expressing critical views about antidepressants on TV

Aku Kopakkala, who worked for Mehiläinen, a private health care organisation in Finland, has been sacked after appearing on a TV programme about antidepressants with Peter Gøtzsche (who I have mentioned in a previous post). Can someone create a better transcript of the programme for me than Google translate? Critical views about psychiatry are discriminated against (see previous post) and this may well be an unfair dismissal.

I see that the Vice President, Working Life Services at Mehiläinen was managing director at Pfizer Oy. And, Erkki Isometsä, Professor of psychiatry at the University of Helsinki, does not seem to have liked being asked on the programme how much he was paid for public speaking by the drug companies. However, this is relevant as he is chair of the Task Force for the National Current Care Guideline for the Treatment of Depression. Confrontation about these conflicts of interest can have destructive consequences.


(With thanks to Jeremy Wallace)

Psychiatry for a new generation

Maybe because I am approaching pension age, I have been thinking about the impact of critical psychiatry on practice. There seems to be little shift in mainstream biomedical bias, which tends to ignore any challenge to its approach. I seem to have been wasting my time trying to get critical psychiatry's message across.

In a previous post, I mentioned Aubrey Lewis, who influenced the generation of professors that I saw retire. I think there's now less passion for thinking about the basis of psychiatry, which he encouraged. That passion has been diverted into promoting neuroscience as the solution to mental illness (eg. see previous post). Trainees are supposed to get excited about discovering the scientific cause of mental illness rather than be interested in the conceptual foundations of psychiatry. I think this is a recipe for disillusionment as fulfillment of this wish is unobtainable.

Of course, psychiatry has always held out the hope that the biological basis of mental illness will be uncovered. However, at times, it seems to have been more open to recognising the uncertainty of human action. For example, Adolf Meyer (see previous post) and George Engel (see conference presentation) encouraged a patient-centred approach to psychiatry. These days, however, a full personal assessment of a patient is almost seen as out of date in psychiatry (see another previous post). Do trainees even know who Adolf Meyer and George Engel were?

So, how can younger mental health professionals be interested in critical psychiatry? They need to be reassured about its legitimacy and not have their careers blighted because they express an interest. Critical psychiatry is not anti-psychiatry, in the sense that it denies the reality of mental illness. It may be almost unbelievable that mental illness is not associated with neuropathology, considering the research effort put into trying to find just that association. But, in fact, the neurobiology of mental illness may be no different from that of our "normal" behaviour (see my article).

I haven't seen any debate about these issues on the Early career psychiatry webpage at Psychiatric Times.