Surely enough money’s been made out of antidepressants

An editorial in Acta Psychiatrica Scandinavica asks whether the time has come to treat depression with anti-inflammatory medication. This is based on a meta-analysis which provides evidence that anti-inflammatory treatment can be beneficial. Throughout this blog (eg. see previous post), I have emphasised bias in clinical trials, so I’m not encouraging the use of anti-inflammatory medication to treat depression. Not least, the trials in the meta-analysis show a high risk of bias and tend to be done by using the anti-inflammatory drug as an add-on to antidepressant treatment, or in patients who have somatic disease, so an anti-inflammatory effect on somatic disease may be the reason for any improvement in depression scores, rather than a true antidepressant effect.

What I want to note is why anti-inflammatory medication, despite the apparent evidence for its benefit, has not managed to be included in guidelines for depression. To gain approval, a large scale trial would need to be done to show that anti-inflammatory medication offers the prospect of better treatment than current treatments, but would be very expensive. As the editorial says, only drugs with a high likelihood of generating future profit are put through such trials. The editorial goes on:-

In the case of the traditionally used, safe and tolerable anti-inflammatory agents that are already on the market, there is no financial incentive for the pharmaceutical industry to conduct these costly, large-scale RCTs. Rather, they are more likely to fund newly discovered immunotherapies with a poorly characterized safety profile, as such novel immunomodulatory treatments can be patented and monetized. 

Unlike the editorial, I am not suggesting government funding for such trials. As I indicated in my review of Ed Bullmore’s book (see previous post), it’s non-sensical to think that depression is a form of inflammation. Any apparent increase in inflammatory markers in depression is far less than inflammatory disease in general, and has non-specific causes rather than being a marker for depressive disease as such (see previous post).

The market for depression has been flooded. The pharmaceutical companies themselves seem to have realised this years ago (see previous post). If people want medication treatment, let’s at least keep it cheap. We should be suspicious of any attempt to make further money out of medication treatment for depression. Marketing and commercial, rather than scientific and therapeutic, interests have always determined which drugs are prescribed.

The stigma of anti-psychiatry

As I said in my previous post, challenging the biomedical model of psychiatry is not anti-psychiatry. Another example of how the term 'anti-psychiatry' is being used by mainstream psychiatry is in a session at the International Congress of the Royal College of Psychiatrists in July this year (see full programme) entitled 'The new anti-psychiatry: Responding to novel critiques on the legitimacy of psychiatry'. The chair of the session is Rob Poole, who I have mentioned in a previous post. The speakers are Paul Salkovskis (again, see another previous post), Dariusz Galasiński (see his blog post about anti-psychiatry) and Linda Gask (see another previous post).

I'm presuming critical psychiatry is what the session calls the 'new anti-psychiatry'. I've argued in a previous post that the Power Threat Meaning Framework that Paul Salkovskis is critiquing is not anti-psychiatry. I'm not sure how new the critiques of critical psychiatry really are; nor that they challenge the legitimacy of psychiatry as such. But I guess this is what mainstream psychiatry thinks is the case, which is why they use the term 'anti-psychiatry’ in the title of the session. As I've said before, it's a pity mainstream psychiatry finds critical psychiatry so threatening (eg. see previous post and extract from chapter 1 of my edited book Critical Psychiatry). There were excesses in anti-psychiatry (see my book chapter) but critical psychiatry shouldn't continue to be tarnished by this rotten reputation.

My own proposal for the International Congress on 'Integrating critical approaches into the training of psychiatrists' was turned down. Jo Moncrieff was going to chair it and the three sessions were on (1) Integrating service user/survivor perspectives (2) Integrating transcultural psychiatry and global psychologies (see new book by Suman Fernando and Roy Moodley) and (3) Integrating critical psychiatry. Maybe the session wasn't accepted because it was seen as too anti-psychiatry. If so, perceptions do need to change about the value of critical psychiatry.

Challenging the biomedical model is not anti-psychiatry

Lisa Cosgove and Jon Jureidini have responded (see article) to a Debate article in the Australian & New Zealand Journal of Psychiatry (ANZJP) criticising the Report, which I have mentioned previously (eg. see previous post), of the United Nations Special Rapporteur on the right to health, Dainius Pūras. This report has also been criticised by the European Psychiatric Association (see previous post). The World Psychiatric Association has also criticised an associated report of Dainius on corruption and the right to health, with a special focus on mental health (see another previous post).

The Debate article is entitled 'Responding to the UN Special Rapporteur’s anti-psychiatry bias'. What it means by 'anti-psychiatry' is challenging the biomedical model and, rather remarkably, it includes the British Psychological Society (BPS) in the global anti-psychiatry movement. The Division of Clinical Psychology within the BPS has produced a valuable position statement on giving up the disease model of mental disorder (see previous post).

The Debate article usefully highlights the right to access to mental health care but seems to limit this right to access to pharmaceuticals. As Lisa and Jon point out, the article mistakenly quotes from Dainius' report saying that it "views inpatient psychiatric care as ‘inconsistent with the principle of doing no harm'" [emphasis in original]. What Dainius actually said was "Overreliance on ... in-patient treatment is inconsistent with the principle of doing no harm, as well as with human rights" [my emphasis]. Furthermore, by quoting Fountoulakis and Möller (2011),  the Debate article seems to think that it has undermined the Kirsch meta-analysis of the effectiveness of antidepressants, which is not the case (see previous post). I don't know what evidence the Debate article is referring to that leads to its conclusion "that many psychiatric presentations are effectively and quickly treated with purely biological treatments".

The term 'anti-psychiatry' has general been used by mainstream psychiatry rather than critics themselves. I don't think it's helpful to polarise debate too much and the Debate article should not use the term 'anti-psychiatry' in this sense. Challenging the biomedical model is legitimate within mainstream psychiatry (see previous post). Critical psychiatry is an advance over anti-psychiatry (see previous post) and anti-psychiatry should not be seen as having had no value (see another previous post). It's difficult to get the right balance about how oppositional to be (see previous post). Certainly dogmatic positions such as that taken by the Debate article need to be challenged.

I'm not sure where the apparent quote in the Debate article comes from about the "creeping devaluation of medicine in UK psychiatry ... [being] likened to ‘throwing the baby out with the bathwater’". As far as I know this isn't happening. In fact, although British psychiatry continues to marginalise critical psychiatry, the British Journal of Psychiatry did publish my editorial on 'Twenty years of the Critical Psychiatry Network'. Let's hope there might be more debate about critical psychiatry in Australia and New Zealand, as well as globally in general (eg. see previous post).


(With thanks to Mad in America post by Zenobia Morrill)