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)