Dr Ellie helpfully exposes bias of “standard NHS advice” about antidepressants

Dr Ellie Cannon found it weird that she was criticised for giving what she considers standard NHS advice about antidepressants on the This Morning TV programme (see her Mail on Sunday article). Although I had some concerns about the wording in places, I was one of the signatories to an Open Letter to This Morning about the segment on the programme in which she appeared.

I don’t want to undermine her faith in antidepressants as she takes them herself, but I do think it is important that patients are given correct information to help them make decisions about antidepressants with their doctor. I’m not convinced Dr Ellie understands the criticisms of what she said by labelling them “anti-psychiatry”. Although she may have been trying to dispel myths, she has perpetuated the myth that depression is due to a “chemical imbalance” in the brain (see eg. previous post). She’s not the only doctor that misleads her patients in this way.

Radical reform of Mental Heath Act

Several of the posts on this blog over the last few years have been on reform of the Mental Health Act in England and Wales, following the independent review chaired by Simon Wessely (see previous post) and the consultation by the UK government on a White paper (see another previous post). Scotland is pursuing its own reforms (see previous post). 

Involuntary mental health treatment must be implemented respecting people’s dignity and their civil and political rights. Complete removal of compulsion, if it can be achieved, will have to be progressively realised, and it should be possible to do this so that it is compliant with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Risk in mental health services is not necessarily best managed by increasing coercion (see eg. previous post).

A new Bill is likely to be presented to parliament next year. The government has decided there will not be a draft Bill for pre-legislative scrutiny. This may be unfortunate as there is apparently considerable uncertainty about the development of policy proposals (see my summary of White paper and government's response to consultation). I fear the Bill may not even go as far as the White paper if there is not sufficient discussion. For example, it's not clear to me how family interests will be protected if the Nominated Person replacing the Nearest Relative is not a family member. Nor do I think it is necessarily sensible to extend holding powers to Accident and Emergency departments. I have deliberately chosen examples which may have appeared to be simple and uncontroversial to show that as far as I can see multiple issues still need to be resolved. How learning disability and autism may no longer be considered as mental disorders for treatment (see eg. another previous post) would be an example of a more complex unresolved problem.

Particular issues I have been promoting on this blog include:-

1. Expanding Mental Health Tribunal powers to decisions about treatment as well as detention (see eg. previous post)
2. Considering a national advocacy service to include Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts (see previous post)
3. Repealing Community Treatment Orders (CTOs) (see eg. previous post)
4. Abolishing Second Opinion Approved Doctors (SOADs) (see eg. previous post) and
5. Prohibiting civil detentions (part II cases) to secure facilities (see eg. previous post)

I understand that the government does not want to reopen issues about reform of the Mental Health Act considering the protest caused by what was supposed to have been a root and branch reform of the Act producing a green paper in 1999 that led to the compromise of the 2007 amendments (see eg. letter from my MP at the time). Nonetheless I do think there are fundamental issues about the rights of people with mental health problems that do need proper debate.

Evidence about antidepressant withdrawal

Vinkers et (2021) helpfully discuss the evidence related to antidepressant withdrawal. As they say:

When faced with the possibility of discontinuation, patients, their family members and physicians fear recurrence of the disorder, and might also fear antidepressant discontinuation symptoms [see eg. previous post] .... The importance and prevalence of antidepressant discontinuation contrast largely with the limited scientific evidence and clinical attention for this topic. ... [D]iscussions ... are particularly driven by opinions or personal experiences rather than evidence.

There are methodological problems of antidepressant discontinuation studies, not least that blinding strategies are often insufficient to properly address placebo and nocebo aspects (see eg. previous post). The review notes that antidepressant discontinuation symptoms even occur in blinded antidepressant arms when antidepressants are continued. Evidence is needed about the underlying mechanisms of antidepressant withdrawal (see eg. previous post). 

As the also helpful NICE draft guideline recommendations make clear:

Dependence is characterised by tolerance (the need for increasing doses to maintain the same effect) and withdrawal symptoms if the dose is reduced or the medicine is stopped abruptly. Addiction also features tolerance and withdrawal but has the additional characteristics of cravings, lack of control, overuse and continued use despite harm. There is considerable debate in relation to these definitions, and in practice, the terms are often used interchangeably. 

Antidepressants do not cause tolerance in the same way as alcohol and opioids. Nor should people who uses antidepressants be seen as drug addicts, in the sense of drug abusers, as antidepressants are not stimulants as such and do not create cravings (see previous post). As I've said several times before, psychological dependence on antidepressants should not be minimised (see eg. previous post). The exact role of any physical dependence needs further clarification.

Do psychiatrists really want to reduce Mental Health Act detentions?

The Royal College of Psychiatrists (RCPsych) is concerned that reform of the Mental Health Act (MHA) will require extra psychiatrists. It has told the Government that proposed changes (see my summary) cannot be absorbed within the existing workforce (see RCPsych webpage). It bases this conclusion on an independent report which it commissioned from The Strategy Unit. 

I’m not surprised by RCPsych’s concerns. The White Paper proposed that detailed Care and Treatment Plans (CTPs)  - for children, young people, autistic and learning disabled people these will be called Care, Education and Treatment Plans (CETPs) - will be put on a statutory footing and must be in place by day 7 of detention and signed off by the clinical/medical director by day 14 and become living documents to be amended and reviewed. The pivotal person to do this work would be the Responsible Clinician (RC), who will usually be a consultant psychiatrist. In its response to the White paper consultation, the government said it would seek to ensure that these new statutory Plans take into account existing requirements round care planning, that they encourage joint working and that there is flexibility regarding the contents of the Plans so that they are truly patient led. The Care Programme Approach is being replaced by personalised care and support planning (see eg. previous post) and I'm not sure if it's clear what impact this is having, and statutory plans need to reflect these changes. The government also said it would work with stakeholders to review the proposed timelines and governance structure to ensure that any statutory requirements placed on staff are aimed at facilitating a culture of high quality, co-produced care and treatment planning for all patients detained under the Act. Even taking the apparent mollification of these statutory Plan requirements following the consultation, the likelihood is that psychiatrists' workload will have to increase to meet the demand.

Actually, the analysis by The Strategy Unit estimated that the primary driver for an increase in psychiatrists will be the additional time required to prepare and attend Tribunal hearings. I'm sure the statutory Plans will be helpful for that preparation. What surprised me was that none of the scenarios The Strategy Unit used anticipated a reduction in detentions (and presumably therefore Tribunal hearings), including what the report called DHSC assumed growth. The impact assessment (see previous post) produced with the White paper assumed that investment in the Long Term Plan in crisis teams and community mental health teams would slow historical increases in detentions, independent of MHA changes. It did not present monetised benefits for the proposed changes in the Act, instead using a breakeven analysis to illustrate the amount of benefits per patient required to offset the costs of the policy. For example, a reduction of 2 days in the average length of detention was said to be sufficient. 

The sensitivity analyses by The Strategy Unit and the government are complex and I'm not sure I understand them completely.  I'm not against increasing the number of psychiatrists, particularly for inpatient work. What I would like to know is what the government thinks the impact on detentions will be of a new Bill, but I guess we won't get this information completely until the Bill is produced next year. Is it really assuming that detentions will continue to increase despite the changes in legislation, as The Strategy Unit seems to suggest? 

In fact, I have been arguing in several previous posts (see eg. Doctors have too much power in the current Mental Health Act) that the proposals do not go far enough to reduce compulsion. For example, repealing Community Treatment Orders (CTOs) (see eg. another previous post) would both reduce coercion and probably costs. The government does not want to re-open this issue as it caused so much controversy when CTOs were introduced by the 2007 amendments to the Mental Health Act (see my webpage, now largely defunct). But the evidence is that they have not been effective (see another previous post). 

Fundamentally, the new Act should help reverse the re-institutionalisation of mental health services that has taken place over recent years (see previous post), particularly by reducing the number of secure beds both in the NHS and private sector. There doesn't seem to be much point in reforming the Act if this process does not lead to a reduction in detentions and enforced treatment. I think detentions can be further reduced, maybe even further than the government seems to think they can be, by repealing CTOs, expanding Mental Health Tribunal powers (see eg. previous post) and improving advocacy (see eg. another previous post). I wish RCPsych would engage more with these issues than apparently seeking to block reforms of the Act, which, after all, are designed to reduce unnecessary coercion.

Are mental health services exploiting the pandemic?

The impact of the COVID-19 pandemic worldwide should not be minimised. Official counts of death may substantially underestimate true death rates, but even these figures show COVID-19 has killed more than 4.5 million people (see article). The grief and disruption to communities and livelihoods is significant.

Understandably there is concern about the impact on people's mental health, not least because of lockdowns to prevent deaths (see previous post). The COVID-19 Mental Disorders Collaborators have recently published a systematic review in The Lancet of what they say is data reporting the prevalence of major depressive disorder and anxiety disorders during the pandemic. However, there were very few surveys that met their inclusion criteria from low and middle income countries. And, most of the surveys used symptom scales that only estimate probable cases of depression and anxiety. And as the authors say, they assumed the predictive validity of such scales remained constant between before and during the pandemic. However, as they also admit, this assumption has the potential to bias their estimates. To quote from them, "For example, high scores on anxiety disorder symptom scales might reflect a natural psychological and physiological reaction to a perceived threat (ie. the COVID-19 pandemic) rather than a probable anxiety disorder".

Similarly, Rethink yesterday released information (now corrected although not sure if there has been sufficient adjustment) suggesting "Symptoms of psychosis soared during pandemic", and this news story was taken up by the media (eg. The Guardian). It's not clear to me that these figures may in fact be due to an artefact, because of how first episodes of psychosis have been counted (eg. see twitter conversation).

What I want to comment on is how people seem to want to use the pandemic to obtain more funding for mental health services. I'm not saying mental health services are well funded. But data by NHS digital suggests numbers of adults in contact with mental health services are not yet back to pre-pandemic levels (see my tweet). Nor is it clear how extra funding would be used, as psychotropic medication and psychological therapy are not necessarily indicated to deal with the stresses and strains of the pandemic. Mental health services do need to be realistic about what they can do to help people (see eg. previous post).

Evaluating ECT effectiveness

Tania Gergel writes a very personal account in BJPsych of the benefits she has experienced from having ECT treatment. She discusses her treatment in the context of the academic literature about ECT and acknowledges that not all ECT recipients have had such positive gains.

I just wanted to pick up what Gergel says about her reasons for dismissing arguments challenging the effectiveness of ECT (see previous post). No-one is denying that ECT can have a placebo effect and I’m not wanting to undermine her faith in her treatment. 

Gergel argues that ECT would not have continued for 80 years if it wasn’t effective. But apparently successful interventions have been removed from medical practice when they have later been considered to do more harm than good. Examples in psychiatry would include leucotomy for psychosis and malarial treatment of dementia paralytica. The originators of both treatments were awarded the Nobel prize at the time because their discoveries were mistakenly thought to be advances in knowledge. In fact Cerletti was also nominated for the Nobel prize for ECT treatment of schizophrenia and manic-depression. ECT is no longer generally seen as indicated for schizophrenia.

Medicine has always exploited the placebo effect. Dramatic treatments like ECT may seem to be needed in desperate personal situations. Of course ECT was first introduced without anaesthesia and muscle relaxants, and such unmodified ECT continues to be given in some parts of the world. 

Doctors’ belief in their treatment and patients’ faith in it is a powerful mutually reinforcing combination (see eg. my book chapter). Randomised controlled trials were introduced to try to move on from the bias of such personal claims. The trouble is that there is still bias in clinical trials (see eg. my webpage). Even if there is a statistically significant difference between ECT and sham ECT in controlled trials, this difference could be because trials are unblinded, for example, through side effects of ECT treatment. For example, trial subjects may become aware that they have had real ECT because of the initial ECT side effects, such as headache. In which case if unblinded, expectancy effects could still be a self-fulfilling prophecy leading to an overestimate of treatment effectiveness. 

In general, we should be sceptical about the effectiveness of medical interventions because research methods are malleable enough to lead to exaggerated positive claims for treatment benefit (see eg. previous post). Individual experiences like that of Gergel, however well expressed in the BJPsych article, do not really solve this issue.

Outcome of maintenance treatment of depression

Gemma Lewis and Glyn Lewis have a further article in The Conversation (see previous post), this time about their recent ANTLER study, which looked at whether patients in primary care who have been taking antidepressants relapse when they stop them. As they say, over the following year, 56% of people who stopped their antidepressants relapsed, compared to a sizeable 39% of people who relapsed even though they continued their antidepressant. 

They then go on to say that the study demonstrated that many people can come off antidepressants safely, whereas I’m not convinced that’s what the study necessarily shows. Of course there are problems with generalising the results of a controlled trial to the real world, and subjects who discontinued their medication in the trial were given placebo, rather than no medication. It would have been interesting to have had a third arm in the study looking at the relapse rate of a no medication group. And to know what happened to the placebo group after the end of the trial. Furthermore, the study does not show whether people can manage without antidepressants longer-term after a year.

The Lewises also say that “Neither researchers nor patients knew which group people were allocated to”. This is not correct, as they report information about unblinding in a supplementary appendix to their paper. They found that “71% (162/228) in the discontinuation group and 47% (108/232) in the maintenance group correctly guessed their randomised group at any time before being unblinded”. People in the trial were better at guessing their allocation if the antidepressant was stopped. Trials typically turn a blind eye to the methodological problems of unblinding (see eg. my eletter). It is possible that the statistically significant advantage found for continuing antidepressant could be due to nocebo amplification through unblinding, in a similar way to which the statistical advantage for the effectiveness of antidepressants could be due to placebo amplification (see eg. previous post). 

People are understandably fearful about stopping antidepressants (see eg. previous post). The subjects in the ANTLER trial were said to feel well enough to consider stopping the pills. From the information in the  supplementary appendix, some seemed to have stopped taking any antidepressant when coming out of the trial, both in the maintenance and discontinuation groups. 

It is not easy to distinguish withdrawal symptoms from relapse. Anxiety about treatment withdrawal can lead to both relapse and withdrawal symptoms (see eg. Moncrieff et al, 2021). Discontinuation problems from antidepressants should not be minimised (see eg. another previous post) and the ANTLER study confirms that long-term outcome of the treatment of depression is not always as good as might be hoped (see previous post). This is a different message from the headline in The Conversation article.