It may be illegal to discriminate against critical psychiatrists

It may now be illegal to discrimate against critical psychiatrists following a ruling that environmentalism is a belief system (see Guardian report). If green beliefs can come under employment regulations on discrimination (although not in the sense of merely belonging to the Green party), then it may well be illegal to discriminate against a critical psychiatrist (although not just because they are a member of the Critical Psychiatry Network or some other group).

Critical psychiatry seems to fit the 5 tests set by Mr Justice Burton:-

 The belief must be genuinely held
 It must be a belief and not an opinion or view based on the present state of information available
 It must be a belief as to a weighty and substantial aspect of life
 It must attain a certain level of cogency, seriousness, cohesion and importance
 It must be worthy of respect in a democratic society, not incompatible with human dignity and not conflict with the fundamental right of others.

Critical psychiatrists have been discriminated against. Trainees are worried that if they express an interest in critical psychiatry, their careers will be affected. Somehow this perception has got to change. A few legal challenges may help.

More advice on long-term prescribing of antidepressants needed

Study in the BMJ looking at why antidepressant prescribing has increased suggests it may well be due to people staying on antidepressants long-term. It only needs a small number to stay on them long-term to increase the total number of prescriptions dramatically.

The problem is that doctors get guidance about starting people on antidepressants but not much about when and how to take them off.

What's wrong with the pharmaceutical industry going bust?

Sarah Boseley has written a Guardian article about a Compass report "A bitter pill to swallow". The subtitle of the report is "Drugs for people, not just for profit".

The report tends to blame the neo-liberal market economics of Thatcher and Reagan for "why the drug companies are getting away with it". There are political changes that could be made, such as that all phase 3 trials be carried out independent from the industry. As the report says, this could be funded through an industry levy as initially put forward by John Abraham and Helen Lawton Smith in their book Regulation of the Pharmaceutical Industry. Doctors' education needs to be through public funding rather than relying on the pharmaceutical industry.

However, things won't really change until it's recognised how much doctors are merely agents of the pharmaceutical industry, rather than independent practitioners in the interests of patients.

More on disparaging postpsychiatry

Nice to have an oldfashioned radical like Rob Poole wading into the debate about postpsychiatry (see the e-letter from Robert Higgo and him in response to Pat Bracken and Phil Thomas's article in Psychiatric Bulletin - see also my previous post). And congratulations on his appointment as professor of psychiatry at Glyndwr University, Wrexham, which is a university that's obviously going somewhere.

I think what Rob and Robert are saying is that their books, Clinical skills in psychiatric treatment and Psychiatric interviewing and assessment are better than Pat and Phil's Postpsychiatry, but there's no need surely to be quite so rude about Pat and Phil's book. I will look at Rob and Robert's books and I'm sure there's something good in them, although I doubt whether they have the same "attitude of provisional scepticism" as Pat and Phil. Still, it's important to recognise the psychosocial emphasis of psychiatrists like Rob and Robert - they at least emphasise the link between mental health problems and poverty.

Let's try and elucidate the similarities and differences amongst psychiatrists that can look beyond a narrow biomedical model rather than get into a slanging match about postmodernism.

International Critical Mental Health Movement

Following the last Critical Psychiatry Network conference held in Norwich (conference website) there has been talk about setting up an International Critical Mental Health Movement. This is not an initiative of the Critical Psychiatry Network, which is a group of psychiatrists, mostly from the UK. It is important that the International Movement is widely based and inclusive.

Please post your comments. Expressions of interest and ideas about how to develop the movement would be welcome. It is envisaged that the International Movement would be open both to individuals and groups, so comments on behalf of organisations will be particularly welcome.

Please circulate interested people and organisations about this posting, so that they can also add their comments.

Critical psychiatry should not be dismissed as anti-psychiatry

At least Pat Bracken and Phil Thomas, advocates of postpsychiatry, have managed to get some response from mainstream psychiatry. They have an editorial in the Psychiatric Bulletin this month, which has an invited commentary from Frank Holloway to which they write an authors' response.

The problem is the way in which critical psychiatry/postpsychiatry gets dismissed as anti-psychiatry. It's not really clear what Frank Holloway means when he says the postpsychiatry project is strikingly similar to the anti-psychiatry of the 1970s. What he implies is that it doesn't really need to be considered. It'll end up in the same dead-end as anti-psychiatry, which was over the top anyway.

It is true there were excesses in anti-psychiatry (see my Historical perspectives on anti-psychiatry). However, the rotten reputation of anti-psychiatry should not be used to hide mainstream's psychiatry's defensiveness about the challenge of critical psychiatry, with which it does need to engage.

Pharmaceutical industry sponsorship of psychiatry conferences

The prospectus for industry sponsorship and exhibition at the 18th European Congress of Psychiatry in Munich in 2010 invites applications for different levels of benefits ranging from platinum to just an ordinary contributor. To obtain platinum, more than 75,000 euros (+VAT) needs to be paid out to be allowed to set up events such as official satellite symposia and "Meet the Professor" sessions. I doubt that the Congress Scientific Committee fails to approve many of these applications, perhaps particularly because the conference would lose the sponsorship money if it did. Full page colour adverts in the conference final programme are allowed by the best sponsors and there are other opportunities for advertising in the conference material. Educational grants in support of particular sessions can be acknowledged in the final programme.

Other options include buying congress bags and the notepads and pens and umbrellas to go in them, sponsoring the presidential dinner and contributing to the Young Psychiatrists' fund. Companies can advertise their logo on computer equipment in the cyber centre, in the facilities for young psychiatrists to review their presentations, in the Speakers' Ready Rooms, on the Congress webcast, and have their name attached to research prizes and scholarship programme winners awards. Just doing a straightforward exhibition also costs money.

I suppose the conference would not run without this sponsorship. Perhaps it's not really an educational event - more a marketing event.

Educational links between drug companies and medical education should cease, as several reports have suggested (eg. recent Royal College of Physicians report Innovating for health: Patients, physicians, the pharmaceutical industry and the NHS see BMJ news report). This means governments being prepared to meet their responsibilities by proper funding for medical education - it should be an element of Barack Obama's healthcare reforms, giving a lead to the rest of the world.


(With thanks to Pat Bracken)

Pseudoneurobiology of addiction

According to an article in Journal of the American Medical Association (JAMA), "During the past 20 years, fundamental advances in the neurobiology of addiction have been made. Molecular and imaging studies have revealed addiction as a brain disorder with a strong genetic component, and this has galvanized research on new pharmacological treatments." This is said without reference.

In a follow-up letter, the authors clarify that they used the term addiction instead of dependence to avoid confusion with physical dependence. "Physical dependence results in withdrawal symptoms when drugs such as alcohol and heroin are discontinued, but the neuroadaptations responsible for these effects are different from those that underlie addiction (compulsive drug-taking condition with loss of control over the intense urges to take the drug even at the expense of adverse consequences)."

Brain mechanisms associated with reward are presumed to be disrupted. Of course, addiction or dependence, whatever you call it, is something to do with the brain. And it's also a habit that may be difficult to break, not least if it's associated with physical withdrawal symptoms. But it's sheer neurologising tautology (as Adolf Meyer used to call it) to think that anything has been explained by calling psychological dependence a brain disorder/disease. It doesn't make sense to say that psychological addiction is caused by a structural brain abnormality, rather than being a functional problem. If specific brain abnormalites have been found in addiction, we'd know what they are.

"I wanted to do something as important as the discovery of penicillin"

A New York Times interview with Nancy Andreasen, author of books, such as The broken brain. She reports what she calls the "big finding" that people with schizophrenia are losing brain tissue at a more rapid rate than healthy people of comparable age. Some are said to be losing as much as 1% per year. This data comes from an unpublished study following up schizophrenics. Andreasen seems to suggest the finding may be due to prefrontal cortical atrophy caused by antipsychotic drugs.

Andreasen says she "sat on" the findings because she didn't want people who need the drugs to stop taking them. Actually, there may be other non-specific reasons why people given antipsychotics have less brain tissue. Any drug effect on brain tissue also may not be of much consequence. But, the problem is the lack of debate. Andreasen is so wedded to the biomedical hypothesis that any potential negative repercussions of her views are suppressed.

How many people need to die each day for it to be an indictment of mental health services?

The Observer, the Liberal Democrats and Rethink argue that four people dying each day in contact with mental health services (Front page news story) shows that psychiatric help is inadequate. The data comes from incidents reported to the National Reporting and Learning Service (Quarterly data summary Feb 2009) resulting in death in mental health settings (most of which will have been suicides).

Actually this data isn't new. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness found 1367 cases of suicide (including open verdicts) of people in 2005 who had been in touch with mental health services within the last year, which is more than the number of NPSA incidents leading to death.

About 27% of people in England and Wales who commit suicide have been in touch with mental health services in the last year before their death. Suicide rates vary by country (see WHO data). Suicide is quite common, certainly in terms defined by the politics of mental health that it reaches the front page of a Sunday newspaper. What suicide rate is it reasonable for a country to have without blaming its mental health services?

Jonathan Leo's not a nobody and a nothing

Jammed by JAMA. Jonathan Leo used to be co-editor of the Ethical Human Psychology and Psychiatry journal. Even if the JAMA editor thinks he's a nobody and a nothing, he isn't. Even a Washington Post editorial talks about JAMA's hush-up. (With thanks to Vince)

Eating disorders 2009

Dr Ian Frampton has got a busy week coming up at the 9th London International Eating Disorders conference 2009, which explains how he's quoted in a story in the Observer Anorexia risk 'could be prevented'. He reckons children could be screened aged 8 to detect a brain problem in the insular cortex that makes them liable to develop an eating disorder. He apparently comes to this conclusion from neuropsychological testing of people aged 12-25 with anorexia nervosa. 70% of these people are supposed to have neurotransmitter damage or subtle brain structure changes or both.

We'll have to see if the papers he's presenting live up to the hype. Looking at the programme for the conference, he's the lead in 4 sessions. The first's called an accessible introduction to the clinical implications of advances in the neuroscience of eating disorders All in the mind? I guess the point he's going to make is that it isn't all in the mind, and that there must be some brain vulnerability in the insular cortex that makes some people more liable to anorexia than others. We then have his presentation of a global neuropsychological assessment in eating disorders. These are the first findings from the Ravello Profile collaboration. In the same short papers sessions, he's also got to present the first findings on testing the insular hypothesis. He rounds up on the last day convening the neuroscience special interest group.

Frampton is one of the authors of a paper from last September The fault is not in her parents but in her insula--a neurobiological hypothesis of anorexia nervosa. This is the element that is picked up by the chief executive of beat, the working name of the charity Eating Disorders Association, based in Norwich where I am. She is quoted in the Observer article as saying "It could pave the way for the first drugs to be developed to treat eating disorders, similar to the way that anti-depressants help rebalance the brain of people with depression. And it will help parents understand that they aren't to blame. Parents always blame themselves when their child develops an eating disorder. But what we are learning more and more from research in this area is that some people are very vulnerable to anorexia and that is down to genetic factors and brain chemistry, and not them trying to look like celebrity models or suffering a major traumatic event early in their lives. This research is a key missing part of the jigsaw of our understanding of anorexia."

This argument has been used to justify biological explanations of other psychiatric disorders, such as schizophrenia or ADHD. It's a misunderstanding of the psychosocial paradigm to suggest that understanding the reasons for something happening is necessarily anything to do with cause, in the sense of a proof of direct one-to-one correspondence.

And should Dr Frampton be allowed to have this publicity before he's even presented his findings? He's gone to the press even before his papers have been put to peer review in a journal.

Oh, and the conference is supported by the Huntercombe group, who have three hospitals for adolescent and young adult eating disorders. One of the convenors of the conference, retired psychiatrist, Bryan Lask, is Medical Advisor and Research Director for the Group.

Is UK improving dementia care?

I still haven't got round to reading the National Dementia Strategy as I said I would. Still the BMJ editorial about it is a good read. It agrees that the evidence for "a memory clinic in every town" is questionable. The French national plan for dementia sounds good.

The drug without the fatal flaw of clozapine

Rolling Stone Bitter Pill story and behind the story.

Time for another hunger strike

NIMH are still getting away with saying that depressive illnesses are disorders of the brain without quoting any evidence. So they're agreeing with the American Psychiatric Association (APA) as I pointed out in my article from a few years ago.

There are massive research interests in psychiatry. If depression is not a disorder of the brain, it would potentially undermine what is called research and development, but despite saying that there have been improved treatments over the last 5 years the APA did not make any effort to explain what these improvements have been in response to a hunger strike in 2003. Would NIMH respond to a hunger stike?


(With thanks to Deborah and Vince)

Don't get an orgasm by pulling a rat out of your mouth

How can a cinema advert by Pfizer, the makers of Viagra, not mention the drug they make? By saying the real danger is counterfeit medicines. The European Alliance for Access to Safe Medicines, which has three out of seven Board Executives who are pharmaceutical representatives, has called the internet the Counterfeiting Superhighway.

And believe it or not, Pfizer has got support from the Medicines and Healthcare products Regulatory Agency (MHRA). But why should the Pfizer campaign focus on the UK which does not allow direct to consumer advertising (except through such campaigns?)?

Pfizer have produced a report Cracking Counterfeit which even pretends they are focusing on men because they're far less likely than women to visit or even be registered with a GP. Actually, as the company information says, Viagra is intended for use only by men. The senior chemist at Pfizer Counterfeit Lab is quoted as saying that rat poison has been found in a counterfeit blood pressure lowering treatment, but doesn't say which drug and doesn't say it's Viagra. By the way, Viagra does reduce blood pressure.

The MRHA makes reference to a brochure Counterfeit drugs kill produced by IMPACT. WHO says it has responded to the challenge of counterfeit medical products by creating a global coalition of stakeholders called IMPACT (International Medical Products Anti-Counterfeiting Taskforce), a partnership comprised of all the major anti-counterfeiting players, including: international organizations, non-governmental organizations, enforcement agencies, pharmaceutical manufacturers associations and drug and regulatory authorities. Why do they need pharmaceutical manufacturers organisations? Do they want them to run for them?

The IMPACT brochure says fake medicines led to a trail of death in Argentina in 2004. A woman was given 7 out of a course of 10 of what the Argentinian medicines authority called "highly toxic counterfeit injections" of an iron-based compound for anaemia, before she died of liver failure. Four people were prosecuted. A second woman injected with the same counterfeit drug gave birth to a 26 week premature baby. No other examples are given of counterfeit drugs causing a "trail of death".

The IMPACT report does point out that some internet pharmacies are completely legal operations. Pfizer uses the IMPACT brochure to say that substandard and counterfeit medicines can lead to death, as well as therapeutic failure and drug resistance.

Survey data found that 67% of men purchasing prescription erectile dysfunction medicine without prescription use the internet. Pfizer helpfully tell you that the legitimate sites that sell precriptions can be found listed at the Royal Pharmaceutical Society of Great Britain (RPSGB) www.rpsgb.org. They presumably get their cut from this site but not from the illegal ones.

Pfizer estimate that over £10 million pounds is potentially being poured into the counterfeit market in the UK. They quote the Centre for Medicine in the Public Interest as predicting that counterfeit medicine sales will reach approx 55.5 billion euros globally by 2010. The Wikipedia entry on this centre says it is "a non-profit medical issues research group which is partially funded by the pharmaceutical industry". Where's the public interest?

The suggestion is that men buy Viagra on the internet because it's cheaper and less embarassing. And they think it is like an over-the-counter drug. Could Pfizer make Viagra more cheaply? Is it too dangerous (watch out for the lowering of blood pressure and Pfizer give warning for cardiac risk of sexual activity in patients with preexisting cardiovascular disease) to be over-the-counter? Does it work?

By the way Pfizer is the world's largest pharmaceutical company. Who are the counterfeiters? Are the regulators doing their job?

And finally, Pfizer have even got Dr Mark Porter supporting them in the campaign. Is there a conflict of interest with his BBC job, presenting Case Notes on radio 4 amongst other activities?

State of mind on radio 4

Good series has just finished. Listen again, I would say, particularly to episode 2 Altered states and episode 5
Which way now?

Has Terry Prachett got dementia?

Terry Pratchett: Living with Alzheimer's 4 & 11 February, BBC Two 9pm. Alzheimer's Disease Society discussion at Talking Point. If he hasn't this backs up the concern about encouraging people to come forward early by the National Dementia Strategy. Who's advising the Alzheimer's Disease Society?

BMJ publishes five commentaries on Doctors, patients and the drug industry. Copy of editor's choice page from print journal.

The critical mental health movement is made up of reformers and revolutionaries

Phil Barker's review of my edited book Critical Psychiatry has provoked me to reply. Comments please.

Improving NHS dementia care

Emma Dent from HSJ's version of dementia strategy. Good to point out that programme of support and counselling at diagnosis can be helpful, although have to be a bit careful about using reduction in institutional care as outcome. The point of the strategy shouldn't just be about reducing number of beds. Relatives may well need respite and even permanent residential and nursing care for demented person considering the burden of care.

How much do care homes make? Are there any figures on this? The government had a choice years ago whether to develop its own provision and chose instead using the profit motive to get enough provision. There's no going back here, but some care owners seem to do quite well out of it. Perhaps they should, but elderly care is not about exploitation.

And I wouldn't like people just to concentrate on information. Looking after someone with dementia has a physical side which must not be ignored. Input is not just about information but also practical help if it's asked for. Dementia care isn't just about advice. Calling people advisors means they may say that's all they can do. What's wrong with calling them consultants? - oh, that's monopolised by the doctors.

Sube Banerjee is right that people do worry they are becoming demented, if that's what he is saying. But it's not just because they really are becoming demented. Information can increase as well as decrease fear, particularly if the problem is incorrectly assessed.

I'm not totally convinced about the resources argument. We have seen a pretty dramatic increase in provision. OK, but so has the rest of medicine as well. As with any mental health care, so much depends on how well it is organised and how good the staff are at understanding what's going on.

I'm not against drop in services. We're supposed to be having them in every local NHS anyway. Are the memory clinics supposed to be part of that set-up? This is getting a bit muddled. I will get to the actual strategy publication soon.


(To be continued)

Dementia strategy published

Health Service Journal version. Are clinics the best way forward? Shouldn't people with dementia be seen at home? Isn't this the history of the development of old age psychiatry in this country? Perhaps history is being reversed.

Good that there's a clinical lead. Problem is that it must remain clinical, not some manager or governance person. There's too much of a divide between managers and professionals in the NHS in general, but maybe having a clinical lead for dementia will help resolve this conflict. But then why just for dementia?

As mentioned previously people with dementia, as opposed to people worrying they have dementia, may not be very good at self-refering. Where's the evidence that early intervention makes any difference? As for psychosis, just because people do worse the later you pick it up, does not necessarily mean that intervening earlier would really make any difference.

I'm not convinced by the strong leadership from the Department of Health idea. They're bureaucrats, aren't they? When did they last see a demented patient? Listen to the professionals.


(To be continued)

Maybe the drug companies really are in trouble

GlaxoSmithKline to slash 6,000 jobs. Competition from generic manufacturers and doubts about company pipelines are posing a serious threat to the sector and ING analysts warned of an "intellectual property meltdown" as top-selling products come off patent and sales slow dramatically.

I wasn't so sure about this in my book review of Marcia Angell's The truth about drug companies: How they deceive us and what to do about it but maybe she was right.

Don't forget to look at the national dementia strategy this week

Health secretary Alan Johnson will unveil the national dementia strategy this week. The government's aim is to raise the profile of dementia, increase early diagnosis and improve the quality of treatment.

There may be a problem with encouraging people to seek early diagnosis. People are not very good at recognising they are dementing. This means dementia may be misdiagnosed when it is really benign forgetfullness or depression.

The drug companies must be laughing about the encouragement of mind-enhancing drugs. These are the same drugs which when I was training were said to be ineffective. Academic old age psychiatrists opposed their introduction then, but now seem to be encouraging the government strategy. Check out any conflict of interest.

Nor do I think there are any intervention studies for changes to diet and lifestyle. Just because there may be associations does not mean they are causal.

Thank goodness for better support for carers but what does it mean?

(To be continued)

Campaign for animals treated with antidepressants

An offshoot blog has been created.

Where did depressed, unpredictable dog bite Jacques Chirac?

Another story about an animal (this time a dog) being treated for depression. This time the problem is unpredictable depression that caused the dog to bite Jacques Chirac, the ex-French president. As I said in the last post, the only licensed indication is for use in separation anxiety associated with behavioural training. It's not clear that the Chirac's dog has separation anxiety - he's living with them, not separated from them, as far as I know. Nor is there any mention of any other loss in the story. No-one seems to have asked why the dog bit Jacques. Nor does anyone seem very interested in where it bit him. The incident does seem serious though as the story describes it as a mauling and the ex-President was rushed to hospital. Should the depression be allowed to excuse the dog's behaviour?

Dogs are being given pills without the evidence. The story doesn't say what antidepressant Chirac's dog has been given. Presumably it's Clomicalm. This blog is prepared to start a campaign for animals being treated with antidepressants. Maybe it will be listened to more than one about humans.

Maybe as a first step someone needs to ask Novartis, the manufacturers of Clomicalm, how much they are making out of the drug. Help please. Join the campaign.

(With thanks again to Cornishcynders. Where do the stories come from?)

Number of tropical birds that require antidepressants is growing

Telegraph story - Parrot is taking Prozac for depression following the death of its owner. Actually it's not Prozac (fluoxetine), probably the most well-known of the newer antidepressants - well, newer in the sense it first went on the UK market in 1989 - but Clomicalm (clomipramine), a traditional tricyclic antidepressant. Most prescribing of psychotropic medication in veterinary medicine is outside licensed indications. According to a recent veterinary psychopharmacology textbook the only label uses in the US for the treatment of behaviour problems are Clomicalm for separation anxiety in dogs and deprenyl for cognitive dysfunction in elderly dogs. So Clomicalm for parrots is unlicensed.

The company product information says Clomicalm was tested in clinical trials involving client-owned dogs. When used in conjunction with behavioural training, Clomicalm accelerated both the time to improvement and the final result of separation anxiety therapy compared to behavioural training alone. So behaviour training is a necessary component of therapy with Clomicalm. Perhaps it doesn't work on its own. The Telegraph story doesn't say whether it worked for the parrot.

(With thanks to Cornishcynders)

Inmates on suicide watch in prison need not be completely naked

Guess who's registered the internet domain preventsuicide.com. It's Ferguson Safety Products. Aren't the models sterotypes? I guess the company must make money. Perhaps NICE should consider assessing the evidence for inclusion in its guideline.


(With thanks to Lou Pembroke)

RD Laing: A new film will tell his extraordinary story

Story from the Independent - R D Laing: The celebrity shrink who put the psychedelia into psychiatry

Read Bob Mullan's biography