Making medicines safer for all of us

Adverse drug events are now the fourth leading cause of death in hospitals.

It’s a reasonable bet they are an even greater cause of death in non-hospital settings where there is no one to monitor things going wrong and no one to intervene to save a life. In mental health, for instance, drug-induced problems are the leading cause of death — and these deaths happen in community rather than hospital settings.

There is also another drug crisis — we are failing to discover new drugs. [Read more...]

Archive for Blog

Magna What? The Embarassing Side Effects of Drugs

Magna Farta

This post is designed to be read with the Drugs and Smell post on RxISK. Click on the image above to read the small text.

Into the Matrixx

The second drug in the Anosmia Table in the Drugs and Smell post is Zinc Gluconate which was traded under the name Zicam. For anyone concerned about adverse events this is one of the most important drugs in History.

Zicam was marketed by Matrixx Pharmaceuticals. The company’s shareholders became concerned about reports it could produce anosmia and parosmia and asked to “look at the books”. The Board said no. The shareholders took them to court and ultimately to the Supreme Court. The company defense was that all it had were animal studies that were not statistically significant and some anecdotal reports of a problem, but as nothing had been properly linked to treatment there was no need to tell the shareholders. The Supreme Court disagreed.

If you are going to gamble with your money, the Supremes figure you are entitled to make up your own mind what the data means but not it seems if you are someone gambling with your life or your child’s life or perhaps the life of child yet to be born or a doctor gambling with your patient’s life.

Blind doctoring

The Supreme Court decision doesn’t stand quite alone though. There is an extraordinary legal case from 1981, Oksenholt vs. Lederle Laboratories, which no one seems to have picked up on.

Dr Oksenholt was sued by a patient whom he had put on a treatment for tuberculosis, Myambutol. This had caused her to go blind. He settled the case with her for $100,000 and then sued the drug company for withholding information from him that their drug could cause someone to go blind. He won the case. He also won $50,000 damages and an unspecified amount for future loss of earnings and $5 million punitive damages. See Oksenholt.

None of the doctors who gave medication to any of the Mass Shooters of recent years or Airline Pilots who have crashed – and there have been many on antidepressants – have interrogated companies legally about the with-holding of data. There is a precedent there for them.

Oksenholt v Lederle Laboratories

This is the third post in the Magna Carta series, a place-holder while we try to FOIA or otherwise find the missing Crusoe Report mentioned in the Witty Report last week. It’s the twenty-first post in the Persecution series.

Illustration: Magna Farta, 2015 created by Billiam James

Magna Pharma

Magna Carta

This post on the eight hundredth anniversary of the signing of Magna Carta is the second in a Magna Carta series, and the twentieth in the Persecution series.

Faced in 2012 with questions about the $3 Billion fine imposed on GSK – triggered by a sequence of events starting with Study 329, – is it just the cost of doing business? Andrew Witty snapped back:

“Although corporate malfeasance cases end up looking very big, they often have their origin in just… one or two people who didn’t quite do the right thing. It’s not about the big piece. The 100,000 people who work for GSK are just like you, right? I’m sure everybody who reads the BMJ has friends who work for drug companies. They’re normal people… Many of them are doctors.

Witty A: Report to the President on changing the system

Accounts of what led to the 2022 Amendments to the Food and Drugs Act vary wildly. Some point to the new President’s first grandson being born with Tetralogy of Fallot linked to the mother’s antidepressant intake. Conspiracy theories invoked Marilyn’s Curse. They noted things like the coincidence of initials between the unknown American Woman whose baby had a Tetralogy of Fallot and Andrew Witty (See American Woman and American Woman 2). Others thought it was triggered by the increasing evidence of cognitive failure in more than one previous President linked by some to the fact both were on Statins.

Whatever the reason, Andrew Witty was recruited from GSK to rewrite the Charter between the people and Pharma. Here is a précis of his option appraisal.

1. Regulation & science

The licensing of drugs is a bureaucratic procedure that has nothing to do with science. As things stand, the way FDA goes about approving drugs has enough of the appearances of science so that most doctors and patients are fooled into thinking there has been a science based decision when there hasn’t.

To an extent the public can’t imagine, the bureaucrats are just interested in getting boxes ticked and to paraphrase Tom Lehrer, “When the drugs go up who cares where they come down, that’s not my department”.

Regulation is completely incompatible with science. Science seeks uncertainty, whereas regulation seeks to abolish uncertainty.

We in GSK thought it must be crystal clear that Pharma does regulation and not science when to support a legal action against the European Medicines’ Agency Data Access policies in 2013 that proposed to let doctors and others see our clinical trial data we argued that this “data” was simply the result of a regulatory exercise and regulators ordinarily maintain the confidentiality of submissions on products they regulate.

This was the winning option in the opinion of the Courts. Some of my colleagues had doubts about our ability to win using this argument while maintaining the illusion that companies do science. The argument was a blow to the self-esteem (amour propre) of FDA and EMA who, while asleep at the wheel, like to claim they base their actions on science.

But medicine predictably noticed nothing. As Thomas More said about the Nobles of England – they’d have slept through the Sermon on the Mount.  The only time they woke up was at Runnymede when there was something in it for them – (see Magna Carta).

2. The effectiveness fly in the 1962 ointment

Regulation needs to be disentangled from science. This cannot easily be done while the 1962 Amendments to the Food and Drugs Act contain an effectiveness criterion. The idea of forcing companies to show their drugs worked was a well-intentioned move but a disaster all round – a simple solution to a complex problem that has made things worse.

In the new regulations to mark the sixtieth anniversary of the 1962 regulations the word effectiveness needs to be replaced by safety.

For those who want companies to say what a drug is for, we can revert to the wording before 1962 by stating a drug should have a clear effect on a structure or function of the body.

Getting rid of the effectiveness criterion would do a lot of things. First it would make it a lot cheaper to develop new drugs. As a result, the cost of drugs would fall, more new drugs would be brought on the market and after marketing a lot of discoveries would be made. We could look forward to a new era of Wonder Drugs to rival the 1950s.

Second it would get rid of off-label marketing at a stroke.

Third it would mean that doctors and patients would have to be personally convinced a drug was actually helping them rather than depend on company claims that it was.

Fourth it there would be much less company clinical trial data and campaigns like BMJ and the Cochrane collaboration to access the data would likely wither on the vine. It would even be safe to appoint Peter Doshi and Tom Jefferson as data access Csars.

3. Evidence based medicine

Whether a drug works or not is not critical to companies but it is critical to medicine and patients. This is a question that cannot be left to industry. As with a lot of these things women have blazed the way as in trials like the Women’s Health Initiative study of HRT. There were earlier trials run by medicine like this during the 1960s but everyone has forgotten them – it’s so long since medicine ran a serious trial.

This would be real evidence based medicine.

One of the consequences of this is that it would likely mean that a full appreciation of the risks and benefits to be obtained from a treatment would only really be clear several years after the launch of a new compound when the proper clinical trials began reporting. What doctors do while waiting for these results to come in is the key issue. Our hunch is that hope is the most powerful incentive of all for most patients and most doctors. No regulatory system will ever change that.

4. Prescription-only arrangements

Quite simply these need to be dismantled. Anyone who doesn’t understand this doesn’t understand marketing – most doctors.

If prescription-only privileges are to be retained in some modified form, only those who do understand the need to abolish them should be involved in any modification.

There are a range of things that could be done such as:

  • Requiring doctors to have a training post in a company marketing department before qualification.
  • All editors of medical journals should have had a spell working in industry first – those without industry experience are too lilly-livered to take to the dance-floor with the amount of confidence needed to pull off any tricky steps.
  • Rewarding doctors for reporting adverse events
  • Penalizing doctors if they do not report them at a certain rate per year.
  • Maintain certain drugs on prescription-only such as cancer chemotherapies where patients are particularly vulnerable and the treatments particularly toxic.

5. Abolish medicine

Where alchemists, homeopaths, chiropractors and others, who have slavishly copied medicine, failed to make inroads, we have been able to walk in and leave with the Crown Jewels.

Using clinical trials and ghostwritten articles – the appearances of medicine – we have infected the body of medicine with an AIDs-like virus turning medicine’s defenses against itself. The insertion of these sophisticated adverts into the medical literature has triggered a Clinical Auto-Immune Deficiency (CID) reaction that leads most doctors and scientists to turn as viciously as they would turn on a quack on anyone who questions the results of these ghostwritten articles and trials that have no data and sometimes no patients. It’s been amazing to watch.

Physicians have had decades to find a way to get this cuckoo’s egg out of the nest of science. They could have based clinical practice only on investigations whose data is publicly available. They could have used the Human Rights of their patients as a lever – it is not for instance possible for any doctor to prescribe any branded medicine with informed consent as things stand at present.

But they haven’t done anything like this. The branches of medicine linked to the prescribing of branded products are finished as a profession. They have no brand value.

The market has now developed so that nurses, pharmacists, clinical psychologists and others can take over the role of prescribing drugs and are far less expensive than doctors.

If medicine has any value and we believe in market forces, abolishing it might lead to a solution. If people and governments come to think they need a set of experts who have brand value when it comes to good quality information on drugs, a new profession will be called into being.

Other physicians practicing in areas of medicine where branded products have little penetration could be allowed to continue.

One issue for others to consider is whether areas of medicine that are heavy users of medical devices are as badly affected as mainstream medicine.

A further option might be a promotion of patient co-operatives. Groups like ACOR.org are making a significant difference to healthcare. They might find it far easier to work with nurse and pharmacist prescribers than with doctors.

6. Boycott

One of the few things that might have influenced my behavior as CEO of GSK would have been a boycott. Record fines and even jail time are not deterrents. Almost everyone views these as a cost of doing business already. A jailed CEO might even boost share value.

We in GSK know that boycotts can hurt. In the crisis over making ARVs available to South Africa for AIDs the threat of a boycott was the only time our Board substantially altered its position.

The boycott would be aimed at getting companies to hand over Adverse Event data. Groups like AllTrials – which we did a lot to nurture – are campaigning for efficacy data. It’s been interesting to watch them punch themselves out on this issue which is tied to disease indications that don’t exist, and center on meaningless surrogate markers, and are produced for bureaucratic purposes only. These data are frankly close to worthless and are not what we have been trying to hide anyway.

What we have been hiding has always been the adverse event data.

7. Rewards

In 1962, in the frantic panic triggered by thalidomide all the wrong options were picked – the effectiveness criterion, prescription-only arrangements, and controlled trials. They all looked good at the time but companies are a bit like the dinosaurs in Jurassic Park, we are always going to find a way around the controls.

There was only one proposed change we really didn’t like and made sure we killed off – this was a proposed revision to the patent arrangements. Having US style product patents has been the key to the Pharma companies becoming Magna Pharma – the most profitable corporations on earth.

Companies need to be rewarded but the current product patents reward us beyond the dreams of avarice for delivering treatments that increasingly shorten life and increase disability.

There are other ways to cut this cake such as process patents, that would make blockbusters less valuable. Process patents would put a premium on diversifying the portfolio of compounds we hold rather than have us dependent on a small number of blockbusters.

At a stroke this would begin to turn us away from making everyone chronically diseased for life in order to make huge amounts of money out of them and away from just looking for drugs that millions will consume even though they don’t need them and turn us toward drugs that everyone will recognize are worth paying a lot of money for.

8. Access to data

The last decade has seen a huge fuss about access to Clinical Trial Data since we in GSK kicked open this door by posting the results of our trials on depressed children on the company website. We have been able to keep the lid on this and have fall back options such as the AllTrials proposals that if adopted will probably leave academics worse off vis-à-vis transparency than they are now.

We have taken some risks to win the argument so far by claiming that patients’ data is confidential – when pretty well everyone who volunteers for a company trial expects that independent experts will get to view the data at some point and would be horrified to find this is not the case. So far this has been a winning argument.

But the startling thing that everyone has missed so far and shows no signs of spotting is that there are thousands or hundreds of thousands of drug trials that remain completely unregistered, where there are no issues of clinical confidentiality. These are studies undertaken in healthy volunteers – normals. There is a compelling cases for ensuring these data are made fully available.

These contain the data we really want to hide – the adverse event data.

Companies will likely need an amnesty for some of the abuses of people that will come to light if the new regulations make these studies available to view.

9. Independent adverse event reporting

This is a key step.

We have taken astonishing steps to prevent decent reporting, or to denigrate reporting when it happens, and to manage the perception of risk rather than risks themselves. If the Nazis had access to our bag of tricks, there would be real and widespread doubt that the Holocaust ever happened.

For instance companies supported the development of an FDA MedWatcher App in 2013. This was widely applauded as we knew it would be. But it was in fact a way for companies to reduce the expense of maintaining a pharmacovigilance department, reduce their legal liabilities, and transform adverse events into anecdotes all in one go. Companies you see have a duty to follow up and decide if their drug caused the problem – FDA don’t have this duty.

But what was astonishing about all this was that pretty well everyone completely bought the idea that when it comes to working out whether a drug has caused a problem, a bureaucrat in FDA who is there because they don’t like meeting patients, has never treated the condition you have and never used the drug you are on, would be better placed than a good team of doctor, pharmacist and informed patient perhaps in touch with other good teams, to work out what’s going on.

If we’re good enough to get people to buy this, perhaps next April 1 we should see if we can persuade people the earth is flat.

Unless an independent patient organization gets involved in assembling real-time data and both doctors and patients combine to put risk mitigation programs in place, the other changes are less likely to work.

The bottom line is the average drug has at least 100 effects. Using clinical trials we have been hugely successful in hypnotizing doctors and patients to focus on one effect and to miss the other 99. This blind spot is the major driver of Pharmageddon (See Marilyn’s Curse).

If the climate change encroaching on healthcare is to be rolled back, we need someone to spit on some clay on the ground, make a paste, and rub it into the eyes of doctors or anyone who ends up prescribing.

10. Shareholding

Following the Supreme Court decision in the Matrixx case (note to self – check I am not confusing this with the movie), which said that while doctors and patients have no rights to access company adverse event data, shareholders have, one option is through Government to give everyone a shareholder stake or stakeholding in companies.

*****

There was a doctor on my panel who had a different point of view. Dr Crusoe. She produced a minority report which I will forward under separate cover.

Magna Carta

Magna Carta

Editorial note: This is the first in a Magna Carta series, and the nineteenth in the Persecution series.

As the days lengthen and things warm up in England, historically it has been the time for the people to get restive.

Eight Hundred years ago, the people meant a group of us who counted – we called ourselves the Barons. There were other human beings – our serfs – who worked for us. Today, in theory even the serfs count.

Next Sunday, June 15, Eight Hundred years ago, we refused to accept King John’s right to rule in England as he had been doing, and confronted the king at Runnymede.

Today’s Barons are the Doctors. Doctors make a living out of the work done by the rest of the population – swallowing pills. These doctors are highly unlikely to confront Andrew Witty or any of the big beasts of the pharmacockracy – unless some of them do so as shareholders.

Eight Hundred years ago a charter was hammered out between us and the king that has since become known as Magna Carta. Today something similar is needed. The forthcoming publication of Study 329 will make clear why.

Up till June 15, John and other kings were absolute rulers, whose right to govern came directly from God rather than from the people. When this right was questioned the Pope weighed in on the side of the king, excommunicating anyone who questioned the authority of the monarch.

Magna Carta was based on two principles – the principle of No Taxation without Representation and the principle of Due Process. These principles are fundamental to most political systems today.

The area of politics that counts most for most of us is healthcare. Big Healthcare is now the biggest business in the United States and in the Western World. We desperately need a new compact between we the people and those who govern our healthcare – or at least a new compact between the doctors who make money for pharma by putting pills in our mouths and the Witty’s of this world.

No taxation without representation

No one bats an eyelid at the idea that the United States is pretty market oriented compared to the more communal or socialist systems found in Europe with Great Britain usually seen as sitting somewhere in the middle.

So it is surprising if you put UK PLC and US PLC into google and see what happens. Google recognizes UK PLC and Great Britain PLC but not US or United States PLC.

There was no google in the twentieth century. Had it been there, it would have started throwing up hits from the late 1960s when British Labour politicians (who used to be very socialist back then) started mooting the idea of UK PLC. The ex-Empire was now a company that had to make its way in the wider marketplace. The Government, we were told, was like the Board. It wasn’t quite clear if the rest of us were the shareholders. We had some notional control over the Board – we could vote them out. Election debates today still mention UK PLC –Scotland PLC hasn’t come on the radar yet.

It’s an odd way to see your country. Neither the US nor any European country views itself in this way. But then the Brits invented PLCs as well as Magna Carta and cricket.

The same idea lies behind the Magna Carta and a meeting of the shareholders of a company – there should be some trade-off between the financial input of the stakeholders in the company (country) and their ability to influence policy. It is worth paying money in the form of investments or taxes if the ship of state is being steered in a reasonable direction but not otherwise.

In health we pay either relatively directly or indirectly through insurance systems or government taxation for the benefits we receive. At present, our barons make money for pharma by putting pills in our mouths but pills that keep companies healthy rather than us healthy.

This happens because of a Flash Boy situation. The healthcare market (stock exchange) should produce better healthcare outcomes (channel money to genuinely productive ends). But neither the stock market nor healthcare support productive outcomes. Both have become a means to siphon money from the middle and working classes to a bunch of Flash Boys. This is possible because as with the stock market, in healthcare no-one gets to see the data behind the transactions. Drugs that are bad for us can be palmed off as life-saving without anyone being any the wiser and we are sold a costly bag of goods.

But we are not just being taxed in terms of the money we pay to consume drugs we don’t need. There is a tribute taken from our bodies also in terms of our participation in clinical trials. Companies need clinical trials to get their drugs on the market in order to make billions from them. These trials involve us taking risks with drugs that often prove too dangerous to market. We do so for free. Not only that but when some of us are killed or injured we collude with hiding the data of our injuries and deaths. We have no more status than serfs.

Or at least this was the way until the clinical trial operation was largely outsourced to India and Africa leaving UK PLC scrambling to persuade GSK, Roche and Pfizer that it is open for clinical trial business and willing to divert its NHS patients into company trials.

It’s this taxation drawn from our bodies that should fuel a demand for representation – we should have a say in deciding what we need medications for and we should have access to the data from trials to check on how it is being represented.

When trials run on our children lead to representations that paroxetine is effective and safe even though the actual data shows exactly the opposite – it’s time to intervene.

Due process

The other key element to Magna Carta was the idea that we are all equal before the law, kings and commoners, and that all have a right to a fair trial.

This principle established the rule of law and laid the basis for democracy. This is a basic Right that provides a basis for all other Rights.

Rather than assassinate the King or seethe with murderous fantasies (Anonymous) we can take him to Court. Rather than be executed at his whim, we have the right to a fair hearing by a Jury of our Peers (Just for the record Peers means other Noblemen).

The capacity of plaintiffs in the United States to take legal actions when they or their families are injured by treatments probably stands between the CEOs of pharmaceutical companies and an attempt to exact physical retribution (See Data Wars and Pharmaceutical Rape).

But even in the United States, there is a real problem. When we participate in clinical trials today, companies get to sequester the data from these trials in flagrant breach of the ethics and norms of science and yet parade their representations of those results as science. The participation of some of us in those trials puts all of us in a state of legal jeopardy. In the US, we may get our day in Court, but we will have the data from clinical trials in which our friends and families participated used against us.

We have entered a bizarre Wonderland where Queen John or Andrew can say off with our head if she wishes to or can say what happens on a drug is what I say happens – regardless of what in fact does happen.

It’s a world where increasingly we will be told by Sense about Science in the UK and related bodies in the US, Canada, Australia or wherever that to question the judgments of the scientific literature is to engage in an irrational War on Science itself. We may have a right to Due Process in the US (nowhere else) but even in the US Courts are no longer a place where rationality prevails.

Not a Peep from the Pope about the right to Due Process or Representation.

Meanwhile David Cameron on behalf of UK PLC has launched into an anti-corruption crusade – but there won’t be a word about this lack of due process or the extraordinary corruption of the scientific literature – on which hinges vastly more money than was ever dreamt of by Sepp Blatter and FIFA.

42 or Thereabouts

42 answer

See previous posts – Switch on Anti-Depression Today and So Long and Thanks for all the Serotonin.

In response to the recent BMJ editorial on serotonin and depression, there were seventeen letters of which three were published, along with my response. These are copied below along with the best letter – by Barney Carroll – which wasn’t published. Make your own mind up as to why.

Another piece of minor intrigue is that this editorial, originally entitled So Long and Thanks for all the Serotonin, a title BMJ felt uncomfortable with, registered well on Altmetric – an index that tracks how much Buzz an article is generating. When I started looking at this, the article was rated at 43 on Altmetric and then moved down to 40 passing through 42 en route. It will presumably pass back through 42 at some point as it gets displaced by Buzzier pieces. Amusing given the Hitch-Hiker link.

serotonin and depression

Healy states the obvious

As a matter of clinical science, the notion of a simple serotonin deficiency in depression ended 45 years ago, when the proposed therapeutic utility of monoamine neurotransmitter precursors was disconfirmed.1 There has been little incisive progress since then, owing to major missteps in the intervening years – for starters, the foolish introduction of generic major depression in lieu of clinically differentiated types of depression as the focus of investigations;2 the displacement of disinterested clinical science by corporate experimercials;3 the corruption of journals and of educational forums by key opinion leaders who promoted corporate marketing narratives;4 and the capture of research funding agencies and regulatory agencies by commercial forces. The discomfort that David Healy’s editorial has caused in some quarters reflects a general embarrassment at the emptiness of current research in mood disorders. The yield has not been commensurate with the billions of dollars thrown at the problem – to the point where most corporations have exited the field out of a healthy self-interest. Little wonder, then, that those who have reason to be embarrassed are now throwing the book at Dr. Healy for stating the obvious.

REFERENCES
1. Carroll B.J. Monoamine precursors in the treatment of depression, in «Clinical Pharmacology and Therapeutics» 12, 743-76 (1971).
2. Carroll B.J. Bringing back melancholia, in «Bipolar Disorders» 14, 1-5 (2012).
3. Carroll B.J. Sertraline and the Cheshire cat in geriatric depression, in «American Journal of Psychiatry» 161, 1145-1146 (2004).
4. Carroll B.J., Rubin R.T. The high cost of non-disclosure, in «Clinical Psychiatry News» 34(10), 27 (2006).

Bernard Carroll

Serotonin and depression – Healy does a disservice to psychiatrists

Alexander E Langford,  South London and the Maudsley NHS Foundation Trust

David Healy does a great disservice to jobbing psychiatrists with this editorial. By portraying them as ‘co-opted into a myth’ about low levels of serotonin being the sole cause of depression he paints them as gullible, and by stating that the same theory is ‘an easy shorthand for communication with patients’ he paints us as lazy and reductionist in our appraisal of the complex and diverse causes of depression.

In reality, good psychiatrists are and always have been only too ready to admit that they are unsure how antidepressants work. Serotonin does play an important role – likely via factors like neurogenesis and gene expression downstream from synapses – but modern psychiatry is way ahead of where Healy seems to think it is. The picture is far more complex. The fact that ketamine has been shown to be useful in depression does not ‘cast doubt on the link between serotonin and depression’, it rather confirms that the neurobiological underpinnings are as multifaceted as we think.

In any case, whatever their mode of action, SSRIs do work. Even the most stringent of analyses (i.e. Kirsch) support this. There is no good evidence that SSRIs work any less well than TCAs for depression , and the SSRIs have not become so commonplace in clinical practice due to some form of pharma-doctor conspiracy, as Healy would suggest, but because the older TCAs have a far less admirable side-effect profile and were also lethal in overdose. The safety of our patients should always come first, and they are far less safe without treatment for their depression.

Healy D. Serotonin and depression. BMJ 2015;350:h1771. (21 April.)

Serotonin and depression: myth or legend?

Philip J Cowen, Professor of Psychopharmacology, University of Oxford,

David Healy’s observations on serotonin and depression make interesting , if familiar, reading [1]. However, I was struck by the remarkable claim that the focus on serotonin has led to the ‘eclipse of cortisol’ in mood disorder research. A quick search in Scopus with ‘cortisol’ and ‘depression’ revealed a rapidly increasing number of published articles from the late 1990s, continuing unabated to the present time. Only last year saw the completion in the UK of a large placebo-controlled study which examined the effects of inhibiting cortisol synthesis in patients with depression refractory to SSRIs[2]. David also manages to suggest that ketamine has been shown superior to SSRIs in melancholic depression whereas no such comparison has been carried out. He further implies that the work of Andrews and colleagues is based on the intellectually paralysing notion that low serotonin causes depression whereas in fact these authors argue exactly the opposite [3].

Should one confront myths by constructing different ones? As an avid BMJ reader I find myself increasingly confused by this question. For if scientific narratives are manifestations of competing power claims and vested interests perhaps there isn’t really a ‘fact of the matter’- the important thing is to be on the right side. I agree with David.

  1. Lacasse JR, Leo J. Serotonin and depression: A disconnect between the advertisements and the scientific literature. PLoS Med 2005; 2: e392 DOI: 10.1371/journal.pmed.0020392 (http://medicine.plosjournals.org).
  2. Watson S, Anderson IM, Apekey TA, et al. Antiglucocorticoid augmentation of antidepressants in depression: The ADD study. J Psychopharmacology 2014; 28 (suppl): A38.
  3. Andrews PW, Bharwani A, Lee K R, et al. Is serotonin an upper or a downer? The evolution of the serotonergic system and its role in depression and the antidepressant response. Neurosci Biobehavior Rev 2015; 51: 164-188.

Serotonin and depression – personalized pharmacotherapy: an interim solution?

Adam M Chekroud. Yale University, USA

Prof. Healy offers an engaging historical perspective on the rise of serotonergic antidepressants that questions their efficacy and biological plausibility. However, this focus on low serotonin levels is a distraction that is basically irrelevant to whether serotonergic antidepressants are effective treatments for depression. It is important to note that response to serotonergic antidepressants appears to be heterogeneous rather than universally poor.  Unbiased trajectory-based analysis of over 2500 patients treated with SSRI antidepressants or placebo indicated that the majority of patients (over 75%) showed a superior response to patients treated with placebo.  However, nearly one quarter of patients treated with SSRIs showed a poorer response than patients treated with placebo. This suggests that in these patients, SSRI treatment actually interferes with their capacity to mount a placebo response, or perhaps even their capacity for resilience to depression [1]. This raises the critical issue of whether there are ways to identify those patients who would seem to be better off avoiding SSRIs and to divert these individuals to other treatments for their depression.

One factor reducing the effectiveness of antidepressants treatment is our inability to personalize pharmacotherapy, i.e., clinicians have no mechanism for predicting whether a particular patient will respond to a specific antidepressant. Instead, the process of matching patients and treatments requires a prolonged period of trial and error, delaying clinical improvement and increasing the risks and costs associated with treatment. Despite important progress in trying to identify depressed patients at high risk of treatment resistance [2], Psychiatry continues to lag behind other specialties like Cardiology and Oncology in which personalized treatment selection is far better established [3,4].

Developing more generally effective treatments and more rapidly effective treatments would be extremely important advances for public health.  However, in the absence of any such silver bullet, we advocate the development and implementation of innovative statistical methods to get the best available drug to each patient, as an interim solution. Personalized pharmacotherapy may still enable us to “save lives and restore function”. Giving up on these patients is not an option.

  1. Gueorguieva R, Mallinckrodt C, Krystal JH. Trajectories of Depression Severity in Clinical Trials of Duloxetine: Insights Into Antidepressant and Placebo Responses. Arch. Gen. Psychiatry. 2011;68:1227–37. doi:10.1001/archgenpsychiatry.2011.132
  2. Perlis RH. A clinical risk stratification tool for predicting treatment resistance in major depressive disorder. Biol Psychiatry 2013;74:7–14. doi:10.1016/j.biopsych.2012.12.007
  3. Kumbhani DJ, Wells BJ, Lincoff AM, et al. Predictive models for short- and long-term adverse outcomes following discharge in a contemporary population with acute coronary syndromes. Am J Cardiovasc Dis 2013;3:39–52.http://www.ncbi.nlm.nih.gov/pubmed/23467552
  4. Roobol MJ, Carlsson S V. Risk stratification in prostate cancer screening. Nat Rev Urol 2013;10:38–48. doi:10.1038/nrurol.2012.225

A pleasing look of truth

I wrote an almost identical editorial as this in 1991 (1). Covering the marketing of serotonin in 1997 (2), I cited Jerome Gaub’s 1767 opinion of Leibniz’ views on the relations of the mind to the body – it is a “fable whose novelty has recommended it, whose recommendation has spread it, whose spread has polished it, refined and adorned it with.. a pleasing look of truth” (3)

I use SSRIs.  Nevertheless I believe the SSRI era will soon stand as one of the most shameful in the history of medicine.  The shame does not stem from what pharmaceutical companies have done, which is just as might have been expected.  The shame will be seen to have arisen from the failure of doctors to know as much as they should have done about medicines they dish out so liberally.  A recent study showing how a dollop of neuroscience dressing can disguise otherwise meaningless material should be compulsory reading for doctors who are after all the true consumers of these drugs (4).

But perhaps an even greater shame will be seen to lie with the fact that this has been an era in which the bulk of publications on on-patent drugs in our best journals were ghostwritten, an era in which the journals refused to demand access to trial data as the price of publication – nowhere more clearly demonstrated than in the area of antidepressant studies on children.  It has been an era when industry has controlled journals, by spending money on some of them and by intimidating others into self-control.

  1. Healy D. The Marketing of 5HT.  British J of Psychiatry, 1991; 158, 737‑742.
  2. Healy D. The Antidepressant Era. Harvard University Press, Cambridge Ma 1997.
  3. Rather LJ. Mind and Body in 18th Century Medicine. Wellcome Historical Medical Library, London, P 17. 1965
  4. Weisberg DS, Keil FC, Goodstein J, Rawson E, Gray JR The Seductive Allure of Neuroscience Explanations. J Cogn Neurosci. 2008; 20, 470–477.

 

Meanwhile the patient information leaflets for pretty well all antidepressants and wannabe antidepressants like quetiapine as of today continue to promote versions of the Low Serotonin Hypothesis (thanks to Julie P for pointing this out).

Citalopram low serotonin

This should incense a lot of people.

Compulsory Vaccination and the Media – The Australian Experience

no vaccinations

Editorial Note: This is another post on the vaccination and censorship theme. Elizabeth Hart’s comments, over the past few weeks in response to some of the posts here, on efforts to stifle debate have been balanced and eloquent. Given the growing number of new journalism outlets, such as The Conversation, that portray themselves as tackling cutting edge issues fearlessly but in fact do no such thing it is a pleasure to help her get a message out that the editor of The Conversation has ignored.

Her interest in the issues began in an unusual way – after her dog died from a booster dose. Checking into it she became aware that pet vaccination is big business and one that has does more for the health of Vets than Pets. This is what radicalized her.

For the attention of:
Mr Andrew Jaspan
Executive Director and Editor
The Conversation

Mr Jaspan

I suggest there are serious problems of bias and censorship at The Conversation and I question whether you are fulfilling your charter.

The Conversation is very ‘pro-vaccination’, there is little in the way of critical analysis of vaccine products. For example The Conversation has helped promote HPV vaccination. I suggest HPV vaccination is controversial, see for example my summary which discusses the questionable way HPV vaccination was initiated in Australia when Tony Abbott was Health Minister in 2006.

The Conversation should be mindful that it has conflicts of interest in that it receives funding from universities that receive funding from the pharmaceutical industry for vaccine research. It seems to me that The Conversation is a marketing arm for the university and research sector.

Today comments were closed down on The Conversation article “Forget ‘no jab, no pay’ schemes, there are better ways to boost vaccination”.

Comments were also recently closed down on “Want to boost vaccination? Don’t punish parents, build their trust” and “’No jab, no pay’ policy has a serious ethical sting”.

I had posted detailed and referenced comments on these articles relevant to vaccine policy and practice, with some still awaiting a response. I had planned to post more comments, but I have now been thwarted in this regard, as ‘the conversation’ has been closed down. Opportunities for serious discussion on vaccination policy and practice are limited in the current hostile climate, and The Conversation does not help by curtailing debate.

Mr Jaspan, Prime Minister Tony Abbott’s announcement that vaccination will be compulsory to obtain family tax benefits is a very serious matter. We are on a slippery slope when governments mandate medical interventions such as vaccination.

There are serious problems with transparency and accountability for vaccination policy in Australia, and I have recently raised this matter with Prime Minister Abbott, see my letter dated 21 January 2015.  There is a serious problem of potential conflicts of interest and lack of disclosure by people influencing vaccination policy.

Tony Abbott, and Opposition Leader Bill Shorten, have reacted to the crude “No Jab, No Play” campaign by News Corp Australia media, e.g. The Sunday Telegraph.

It appears the vigilante pro-vaccination group SAVN (Stop the Australian (Anti) Vaccination Network) was also instrumental in this campaign. It also appears The Conversation is a supporter of SAVN, as evidenced by its publishing articles by self-avowed SAVN members, e.g. Rachael Dunlop and Patrick Stokes. It is notable that Patrick Stokes’ membership of SAVN is not included in the Disclosure Statement on his article “No, you’re not entitled to your opinion”.

I have tried to raise serious discussion about vaccination and individual vaccine products on The Conversation as my ‘activity’ illustrates, but I have often been impeded by followers of the SAVN who colonise comments threads on vaccination articles on The Conversation.

I was astonished today to discover that SAVN member Patrick Stokes has the ability to ‘hide’ (i.e. censor) comments on articles on vaccination on The Conversation, (see discussion between Patrick Stokes and Adam Bonner on “Forget ‘no jab, no pay’ schemes, there are better ways to boost vaccination”). Patrick Stokes is hardly an impartial arbiter, on what basis have you given him this power?

I also suggest there are serious problems at The Conversation in regards to proper disclosure of authors’ potential conflicts of interest. In this regard see my discussion with Professor C Raina MacIntyre on the “Want to boost vaccination? Don’t punish parents, build their trust” comments thread.

It is also ironic that experts on vaccination such as Professor MacIntyre and A/Professor Kristine Macartney do not appear to understand the difference between ‘vaccination’ and ‘immunisation’, and incorrectly use these words interchangeably, another point I raised on their articles. If ‘experts’ are so careless with the basics, what else are they getting wrong?

Mr Jaspan, compulsory vaccination is at odds with the requirement for ‘valid consent’ before vaccination, see Section 2.1.3 of The Australian Immunisation Handbook.

I suggest there should be an investigation into the aggressive campaign to make vaccination compulsory in Australia, and the tactics used by News Corp Australia, SAVN, and The Conversation.

Yours sincerely

Elizabeth Hart

http://over-vaccination.net/

Elizabeth Hart

The Couric Incident: HPV Vaccine & Mass Bullying

Katie Couric

Editorial Note: This post is by John Stone at my invitation. I am broadly speaking pro-Vaccination and reluctant to stray into the Vaccination Wars but the issues about free debate in recent posts seem most acute in this domain. Anyone who even thinks about questioning is vilified.

There are important public policy issues involved in MMR but less so with the HPV vaccine and the Flu Shot. For many working in healthcare, the Flu Shot is worrying. While in Britain it is not compulsory, there is a lot of pressure even though the case for having it seems weak. Elsewhere Flu Shots have been made compulsory. I’m sure many of us wonder what we would do if put on the spot like this.

Some of the strongest Vaccination advocates double up as Pro-Transparency campaigners. A Furor Vaxicanus just doesn’t seem to match up with transparency. John Stone is a Vaccine Safety Advocate who to my mind has also been one of the most reasonable voices commenting on some of the posts on this site over the last year. I don’t know John from a bar of soap (as we’d say in Dublin).

But I do know Rokuro Hama whose work John cites here. Rokuro and the group behind MedWatcher Japan are the most extraordinary courageous scientists and lawyers and all round safety advocates there are. Their MedCheck Bulletin is being made available in English for the first time this week and will be worth following – see MedCheck.

The point being raised by Rokuro goes to the heart of Evidence Based Medicine. When “girls” complain of serious problems after Gardasil or Cervarix, what weight do we put on what they say? What weight do we put on what we know about the biology of the HPV vaccine? What weight do we put on the fact that any effort to ask about this runs into media flak from SMC UK,  or SMC Australia, SMC Canada or SMC USA?      

Katie

In 2012 Katie Couric was the best paid media presenter in the United States, referred to as America’s Darling. Late in November 2013 it was announce that Couric was to give room in her ABC Television show Katie to the subject of vaccine injury from HPV vaccine. The result was an immediate furore.

Wiki recalls aspects of this historic episode:

In December 2013, Couric ran a segment on the HPV vaccine…which critics accused of being too sympathetic to the scientifically unsupported claims that this vaccine was dangerous…For example, Seth Mnookin accused her broadcast of employing false balance. In addition, Alexandra Sifferlin, of Time magazine, compared Couric to Jenny McCarthy, a well-known anti-vaccine celebrity…On December 10, 2013, a week after the original segment was aired, Couric posted an article on The Huffington Post responding to this criticism, in which she stated:

“I felt it was a subject well worth exploring. Following the show, and in fact before it even aired, there was criticism that the program was too anti-vaccine and anti-science, and in retrospect, some of that criticism was valid. We simply spent too much time on the serious adverse events that have been reported in very rare cases following the vaccine. More emphasis should have been given to the safety and efficacy of the HPV vaccines.”

The show which was falling in the ratings was due to be taken off the air the following summer was suddenly terminated 19 December, but not before a follow-up program had been screened giving all its room to the vaccine advocates. This was obviously a huge professional humiliation for Couric, but it was not the whole of the story: on Couric’s website a gigantic battle raged between families of injured people supporting the show and an angry mob of “skeptics” – many of them Australians – who ridiculed them. There were probably more than twelve thousand posted comments in all: more than a thousand apparently came from the keyboard of ubiquitous vaccine program advocate Prof Dorit Reiss, an academic (but not qualified lawyer) from Hastings law school in San Francisco, which is in partnership with Kaiser Permanente who were hired by Merck to study the post-marketing effects of their HPV vaccine Gardasil. Kaiser Permanente are also partners with Centers for Disease Control. While Reiss was more well-mannered than most of the vaccine advocates she dismissed any attempt to discuss vaccine injury as anecdotal, and her tactics were copied and deployed more brutally others. Many people, of course, speculated on how she could post so often while carrying out her professional duties at Hastings.

The episode also closely echoed a campaign earlier in the year to have Jenny McCarthy – widely labelled “anti-vaccinationist” – excluded from broadcasting, an episode which also involved Reiss and her colleagues at Voices for Vaccines. V4V also parades as not accepting pharma money but is in fact an off-shoot of Task Force for Global Health, which does accept pharma money, and is in partnership with the Centers for Disease Control. It is interesting to note that the chair of Task Force’s Board of Directors is leading Atlanta product liability lawyer Jane Fugate Thorpe.

The view from Japan

It should be evident, whatever the words of Couric after the event, that these are not stories about science asserting itself but of corporate leverage and internet bullying. The strategies and their effect say nothing about the quality of the science at all. They speak to the ethics of the proponents. It is particularly salutary to view these events against the background of a recent review of the evidence in the independent Japan Institute of Pharmacovigilance  bulletin Med Check – The Informed Prescriber (editor-in-chief Rokuro Hama). Hama is also a special advisor to the Cochrane Collaboration:

Harm of HPV

Abstract: Incidence of serious adverse reactions to HPV vaccine is 3.2% per year according to our  recalculation using the latest data (3,200 cases per 100,000 person years). This is almost equivalent to the incidence rate of serious adverse events within 1.2 years after the first vaccination (annual rate of 2.8%) reported in the randomized controlled trials (RCT) of Cervarix. In Cervarix RCTs, the excess incidence of serious reactions, autoimmune diseases and death after 3.4 years comparing with those during 1.2-3.4 years was calculated as 4,000 patients, 630 patients and over 100 deaths per 100,000 person-years respectively. These might also occur in Japan. As to the epidemiological surveys from Europe and North America that Japanese Ministry of Health, Labour and Welfare (MHLW) based on as the evidence for safety of the vaccine have flaws in their methodologies. One study confuses prevalence with incidence, and the other two have serious bias derived from “healthy vaccinee effect”. While there is no evidence confirming that HPV vaccination decreases incidence of and mortality from cervical cancer yet, supposing that the vaccine could halve the cervical cancer mortality, the expected maximum benefit would be two deaths per 100,000 person-years at the most. Hence, the harm experienced is overwhelmingly greater than the benefit expected.

The DisUnited Kingdom

In the United Kingdom media reporting of the harms of HPV vaccines has died out since 2009. An article in the Sunday Express by Lucy Johnston, much sneered at by Ben Goldacre in the Guardian, reported much the same thing as Med Check:

The cervical cancer vaccine may be riskier and more deadly than the cancer it is designed to prevent, a leading expert who developed the drug has warned. She also claimed the jab would do nothing to reduce the rates of cervical cancer in the UK. Speaking exclusively to the Sunday Express, Dr Diane Harper, who was involved in the clinical trials of the controversial drug Cervarix, said the jab was being ‘overmarketed’ and parents should be properly warned about the potential side effects.

It looks as if the article was withdrawn after a complaint by Dr Harper because she had alluded to the aggressive marketing of Gardasil by Merck in the US when the main topic was GSK’s Cervarix and this was not clear in the otherwise sound report. Be that as it may this is still a vaccine where the benefits are six years later still entirely theoretical and speculative and there are apparently many injured young women.

They and their families should be allowed to speak to the world without harassment. The public pay for these very expensive vaccines twice, first through the public purse, then through the harms they inflict. 

So Long and Thanks for all the Serotonin

Leunig depression cartoon

The BMJ article on Serotonin and Depression has stirred some interest. There are some highly technical comments on the BMJ site but of course the key point behind the piece is the rather obvious fact that twenty-five years ago many people were saying it was all a myth. The extraordinary Michael Leunig nailed it twenty years ago in the sketch above. (Leunig is wonderful across the board and razor sharp on medicine and mental health).

So did the BMJ know what they were doing when they sent the article to the Science Media Centre leading to the extraordinary new Switch on Anti-Depression (SAD) theory?

I thought they were making a mistake, but maybe not. The figures for impact from Altmetric show a lot of interest.

serotonin and depression

There are good grounds for a lot of people to be very angry.

The lawyers for several pharmaceutical companies for instance claim to be very angry and upset by recent posts mentioning that finding out about things such as the idea that lowered serotonin was a myth could provoke murderous fantasies in some people, most of whom would do nothing but simmer and seethe. They have been even more upset at the suggestion that while some of us can view all this as “academic” others might be radicalized and might storm the offices of pharmaceutical companies or journals.

See War on Civilization and Pharmaceutical Rape.

serotonin and depression

Our rulers are exquisitely aware of the potential for violence in those who are oppressed – those who are powered out. The violence inflicted on us – mostly by White Males – from Ferguson and Charleston to Baltimore playing out across television screens for the last year offers just one example. They expect Us to be as violent back as they are to US, and they tend to take pre-emptive action. At the first FDA Prozac and suicide hearings, the Chairman Daniel Casey wore a bullet-proof vest.

Clearly there has been no endorsement here for violent action but as one correspondent (MMC) put it, we sent Marlboro Man packing and something similar is needed here.

serotonin and depression

Better Die on your Feet than Live on your Knees sounds violent but was in fact the rallying cry of the Non-Violent Resistance movement that began in Ireland in the 1870s with Michael Davitt and later extended to Mahatma Gandhi and Martin Luther King.

If you want to see what is involved, fill a RxISK report on your behalf or someone close to you and take it to your/their doctor. There is a good chance you’ll find out just how violent the system is.

But keep knocking until you find a doctor who listens, let us know about them and we can build networks that can change medicine. It is only going to change from the Bottom Up.

Switch on Anti-Depression Today

5794416589_bb14397d5f_z

Science Media Centre roundup

Expert reaction to editorial on serotonin and depression as published in The BMJ (British Medical Journal)*

Dr Clare Stanford, Reader in Experimental Psychopharmacology, UCL, said:

“Prof David Healy’s article treads a path that is well-worn but out of date. He argues that selective serotonin re-uptake inhibitors (SSRI) antidepressants are used because of a pervasive myth that they boost serotonin levels, but this is something of a straw man. He makes the mistake of assuming that antidepressants reverse a functional abnormality in the brain that causes depression. Actually, the theory that low ‘levels’ of serotonin in the brain (whatever that means, functionally) causes depression died many years ago, in spite of the fact that a deficit in the synthesis of serotonin in the brain can trigger relapse of depression in some patients who are in remission: a fact which he also fails to mention.

“By contrast, the monoamine theory of ‘anti-depression’ is alive and kicking. There is plenty of evidence that SSRIs increase communication from neurones that release serotonin, as well as other monoamine transmitters, and that the ensuing downstream changes, such as creation of new neurons (neurogenesis) or modification of gene expression, can ameliorate depression.

“In short, SSRIs probably switch-on anti-depression, rather than switch-off depression (which could explain the rapid efficacy of ketamine).”

“I am sure that most clinicians and scientists will be dismayed that a flawed argument is used to underpin a suggestion that the use of older tricyclic antidepressants, which are so dangerous in overdose, is always preferable to the SSRIs.”

 So long and thanks for all the fish

The BMJ editorial that the Science Media Centre are referring to is Serotonin and Depression. It was originally called So Long and Thanks for all the Serotonin.

The first thing about the Science Media Centre comment is it’s wild. It completely misreads the editorial it’s commenting on – at no point does the editorial say I or any academic ever believed the serotonin hypothesis or changed our beliefs because it has now been debunked.

In an extraordinarily brief space Clare Stanford introduces a whole new concept Switching on Anti-Depression – that no one I know has ever heard of. And also manages to say that there was never any evidence for the serotonin hypothesis but that the serotonin hypothesis is right anyway.

It’s hard to believe Clare Stanford wrote something like this.

Which raises the question – who are the Science Media Centre? There were several posts last June about the Science Media Centre and Sense about Science – see Follow the RhetoricFirst Admit no Harm, Follow the LawsuitFollow the Patient – cover aspects of what’s at stake. This is an organization that under the umbrella of taking a responsible approach to science ends up denigrating a lot of work or researchers that raise concerns about anything that might harm a corporation’s products.

Following the successful establishment of a UK SMC, comparable groups have been set up in Australia, New Zealand and Canada. See SMC Feasiblity Study for a document apparently stemming from a consultation exercise about what a Canadian SMC might look like.

Earlier this year a fuss blew up about coverage of HPV vaccines in the Toronto Star. The Star backtracked from its article, persuaded in part it would seem by input from SMC Canada that the Sixty cases of injured girls they had were just “anecdotes”.

The BMJ and other journals and media outlets divert a large amount of their content via the British SMC these days. They seem to think that this will increase coverage of their content – when the SMC is much more interested ordinarily to close down stories like this one rather than open them up. “We get our experts – who are usually media trained – to tell your journalists why you don’t want to bother with this story”.

Why do BMJ do this?

Who are the US equivalent of SMC?

A Broken Utopia? The Internet and Health Activism

digital abstract

Editorial Note: This post by James Bennett, a research coordinator on RxISK, follows on from last week’s Everyone has the right to challenge “Scientific Experts”. The article accompanying the image of War on Science from the National Geographic featured in that post made the case that we increasingly live in a world of tribes – the tribes who see vaccination as an unmitigated good or a harm, the tribes who believe in climate change and those who don’t and most of us get our views from the Tribe we belong to rather than think them through ourselves. When it comes to your health a tribal response is rarely a good thing. The reason we make drugs available on prescription only through doctors was supposed to be as an aid to each of us to hang on to the middle ground between company marketing and complementary or alternate medicine. But rather than be a bulwark against tribal responses, all too often doctors seem to lead the pack.

The Internet has had a huge impact on many aspects of life, including the way many of us deal with matters concerning health. Whether just looking for lifestyle tips or seeking detailed help for a specific diagnosis, we now have the ability to access information from health organisations, doctors and medical researchers on a global scale.

Some may be able to seek out treatment ideas that they simply wouldn’t have known about. Not only is there greater scope to connect with health professionals, but we also now have an unprecedented ability to share knowledge and experiences ourselves.

One of the areas that has seen significant changes is mental health. Day or night, sufferers can now connect instantly with others like themselves in forums and social media groups all around the world, who can offer advice and emotional support.

Through these new media channels, mental health has become a hot topic, with charities and other organisations reaching out to the public to raise awareness and to educate.

Such a scenario would previously have been unimaginable. But, behind the Utopian facade there are some less desirable realities.

Fractured approach

Medication has increasingly become the first line strategy for dealing with mental health issues, with antidepressants being among the most commonly prescribed drugs.

However, there is significant reluctance from many involved in mental health, both professionally and in voluntary groups, to discuss serious side-effects. While the influence of pharmaceutical companies is never far beneath the surface, things have taken an usual turn. Many who are antidepressant users themselves are now behaving in the same way – not discussing issues.

As a result, a degree of duality has emerged on the Internet, with websites and social media groups often falling into one of two categories:

The first provides mental health advice and support, either for a range of issues or one specific area such as depression or anxiety. However, information about serious drug side-effects is often minimized or omitted completely. Discussion of the risks is sometimes not welcome.

The second category deals specifically with iatrogenic problems caused by psychiatric treatments. They raise awareness of the issues, and provide emotional support and technical advice to people who have been harmed. This can include those who are withdrawing from psychotropic drugs – a process which can last for months or even years.

In November 2013, we published a set of e-mails between RxISK and a leading UK mental health charity, which perfectly highlighted an unwillingness to be candid about medication risks. The article can be found here.

The cure or the problem?

Medications for various conditions can have emotional and behavioral side-effects. This is something that can impact those using anti-epilepsy drugs for example.

The same is true of antidepressants. They can cause a range of problems including depression, anxiety, panic attacks, aggression, apathy and emotional numbness. This is vital information for users, but it is something that many mental health organisations rarely divulge on their websites in any substantive way.

It is clear that some sufferers do make a link between psychological effects and their medication, particularly when a problem occurs suddenly, such as when switching to a new drug. But, problems can develop more gradually over time. Coupled with polypharmacy and multiple dosage changes, the issue can become clouded and there is less chance of the treatment being called into question.

A serious problem that generally receives only a cursory mention, if at all, is akathisia. Described as a sense of inner restlessness, it is a complex and highly destructive side-effect of various psychotropic drugs. It can manifest as a physical inability to remain still, but can also be less obvious, presenting as anything from a constant and disturbing unease in the mind, through to an intense emotional turmoil.

It is a similar story for withdrawal. Websites sometimes mention that antidepressants should be tapered carefully, but they are often vague on the details. Despite the well-established 10% reduction protocol, it is still common to see reports in social media from those who tapered over just a few weeks or by taking the medication on alternate days, and then experienced what they believed to be an immediate relapse.

For more information on withdrawal, please see the Guide To Stopping Antidepressants on RxISK and the forthcoming Withdrawal Forum.

The stigma divide

Those who use social media will probably be familiar with the concept of mental health stigma and the anti-stigma campaigns. This refers to the scenario where people find themselves treated differently, and unfavorably, after revealing that they are suffering from a mental health issue. As a result, they can be reluctant to speak out about their problem or to seek help. The campaigns look to address this by raising awareness and by attempting to gain greater social acceptance of mental health problems.

However, this is not the full story. The campaigns fail to mention that those who have been injured by antidepressants and similar drugs, as well as those working to support them, are also victims of stigma. They are often labelled as anti-medication, anti-psychiatry, and are generally seen as trying to upset the natural order of things. Ironically, this is often perpetrated by those who are antidepressant users themselves.

The medical profession is often equally misinformed about medication adverse events and can be hostile or apathetic toward those seeking help, even where the iatrogenic nature of the problem has been acknowledged.

Those who received support while believing they were suffering from a long-term mental health problem, can quickly become outcasts after discovering that their problems were exacerbated or even caused by their treatment.

Illusion of knowledge

Despite the advent of the Internet, increased media coverage and general efforts to raise awareness of mental health, in many ways the situation has actually deteriorated. Much of the information that people need is missing from the places they are most likely to be looking.

While a lack of knowledge can be a problem, the illusion of knowledge is even more hazardous. There are many people who now believe they have a comprehensive understanding of their issues, yet appear to know very little about their medication and how it might be affecting them. Efforts to restrict this information only serves to undermine and discredit the message of empowerment within mental health.

In terms of those antidepressant users who contribute to this problem themselves, there may be no single explanation. It could be a combination of factors.

For some that have connected with other mental health sufferers in Internet groups, perhaps the sense of belonging – the shared experience – becomes more potent than the need to understand the experience itself.

In some cases, the drugs themselves may also be playing a part. Those who have successfully withdrawn from antidepressants often did not realize how their judgement and perception was being affected, until they stopped.

The fact that antidepressants can cause serious psychological problems is seen as threatening to invalidate the experiences of those who are happy with their diagnosis and their medication. Attempts to discuss the issues are sometimes regarded as an attack on pro-choice, when in fact it is the opposite.

The greater good?

It is sometimes said that publicizing the risks of antidepressants and similar drugs would cause distress and lead people to discontinue their treatment. Ironically, withholding this information can also cause distress and result in poorer outcomes, as side-effects become mistaken for features of an ongoing or worsening mental health problem.

Interestingly, there is an element of this approach on both sides of the divide. Concerns that legacy-effects may be permanent are sometimes met with solid reassurance that this is definitely not the case, and they will resolve in time. Those who offer a less certain prognosis can be met with criticism for damaging people’s hopes of recovery.

The reality is that while some people do improve and would even go as far as considering themselves recovered, others are still experiencing significant problems many years later. Clearly, tact and sensitivity are called for, particularly when sufferers are in withdrawal. But nevertheless, it is an interesting observation that people on both sides of the line are willing to present a particular narrative when they believe it is in someone’s best interests.

The future

The Internet is both friend and foe. It has empowered a great many people, and allowed them to take control of their health and their lives. It has connected people in a way that would otherwise have been impossible.

But, the Internet is also a breeding ground for misinformation and has provided another avenue for the influence of pharmaceutical companies to pervade the consciousness of the general public. Critical mass may have been achieved, as the message to oppose discussions of side-effects and to regard the injured as purveyors of stigma, has now become self-sustaining within the mental health community itself.

There is a wealth of information in the public domain about psychotropic medications, from side-effects while taking them, through to withdrawal and legacy-effects. But, the newly diagnosed are unlikely to be looking for this, so it becomes limited to assisting those who already suspect that something is wrong and are seeking answers. It becomes damage control rather than being preventative.

The problem is complex. Efforts to tackle it must be robust, but also carefully considered. Spreading the message is important, but on its own may not be enough to bring about real change, and in some cases can be counter-productive. Adverse events on prescription drugs need to be reported, and the healthcare system needs to be pressured into dealing with them.

The time to act is now, before the fractures in the health landscape become too deep to repair, and any possibility of genuine empowerment is lost.


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If you are experiencing prescription drug side-effects, please complete a RxISK Report to discuss with your doctor.

Everyone Has The Right To Challenge Scientific Experts

the war on science

Editorial Note: This post is from John Horgan who writes for Scientific American. The original is here. There is one change – the image used. JH’s posts are always worth reading. In this he takes on a worrying trend to regard science as sacrosanct. A recent front cover for National Geographic brought this home to me. To question whether vaccines might cause autism it seems is pretty well to be a Flat Earther. This has clear and worrying implications for me, for RxISK and for anyone who has ever been injured by a drug.

Years ago I was blathering to a science-writing class at Columbia Journalism School about the complexities of covering psychiatric drugs when a student, who as I recall had a medical degree, raised his hand. He said he didn’t understand what the big deal was; I should just report “the facts” that drug researchers reported in peer-reviewed journals.

I was so flabbergasted by his naivete that I just stared at him, trying to figure out how to respond politely. I had a similar reaction when I spotted the headline of a recent essay by journalist Chris Mooney: “This Is Why You Have No Business Challenging Scientific Experts.”

(Journalist Chris Mooney argues that the views of anti-vaccine activist Jenny McCarthy can be dismissed because she is not a “scientific expert,” but by this logic the views of journalists like Mooney should also be discounted).

Mooney is distressed, rightly so, that many people reject the scientific consensus on human-induced global-warming, the safety of vaccines, the viral cause of AIDS, the evolution of species. But Mooney’s proposed solution, which calls for non-scientists to yield to the opinion of “experts,” is far too drastic.

In support of his position, Mooney cites Are We All Scientific Experts Now?, a book by sociologist of science Harry Collins. Rejecting the hard-core postmodern view of science as just one of many modes of knowledge, Collins argues that scientific expertise is uniquely authoritative. Here’s how Mooney puts it:

“Collins carefully delineates between different types of claims to knowledge. And in the process, he rescues the idea that there’s something very special about being a member of an expert, scientific community, which cannot be duplicated by people like vaccine critic Jenny McCarthy… Read all the online stuff you want, Collins argues—or even read the professional scientific literature from the perspective of an outsider or amateur. You’ll absorb a lot of information, but you’ll still never have what he terms ‘interactional expertise,’ which is the sort of expertise developed by getting to know a community of scientists intimately, and getting a feeling for what they think. ‘If you get your information only from the journals, you can’t tell whether a paper is being taken seriously by the scientific community or not,’ says Collins. ‘You cannot get a good picture of what is going on in science from the literature,’ he continues. And of course, biased and ideological Internet commentaries on that literature are more dangerous still. That’s why we can’t listen to climate change skeptics or creationists. It’s why vaccine deniers don’t have a leg to stand on.”

Mooney is hardly the only person insisting “You Have No Business Challenging Scientific Experts.” Versions of this assertion constantly pop up in debates over hot-button scientific issues. Defenders of supposedly canonical views of global-warming, genetically modified foods and vaccines dismiss non-expert dissidents. Just last week, a friend and fellow journalist mocked meteorologists who doubt climate change–because they’re meteorologists, not climate scientists.

The irony is that the “No Business Challenging Scientific Experts” argument applies not only to activists like Jenny McCarthy but also to journalists like Mooney and me. After all, we journalists are “outsiders” and “amateurs,” especially compared to the scientists whose work we cover, so how dare we second-guess them?

I agree with Mooney and Collins on some fundamental issues. I’m not a Kuhn-style postmodernist, the kind who puts scare quotes around “truth” and “knowledge.” Science is a uniquely potent method for discovering how nature works, and it gets some things right, once and for all: the atomic theory of matter, the (basic) big bang theory, evolution by natural selection, DNA-based genetics.

Also, I give great weight to consensus and credentials, which provide a fast and dirty way to decide whether a claim should be taken seriously. One of the reasons I doubted that “cold fusion” had been achieved in the late 1980s was that scientists claiming to have observed room-temperature fusion tended to be at second-rate institutions; scientists at top-tier institutions could not replicate the results.

But the history of science suggests—and my own 32 years of experience reporting confirms—that even the most accomplished scientists at the most prestigious institutions often make claims that turn out to be erroneous or exaggerated.

Scientists succumb to groupthink, political pressures and other pitfalls. More than a half century ago, Freudian psychoanalysis was a dominant theory of and therapy for mental disorders. The new consensus is that mental illnesses are chemical disorders that need to be chemically treated.

This paradigm shift says more about the financial clout of the pharmaceutical industry–and its control over the conduct and publishing of clinical trials–than it does about the actual merits of antidepressants and other drugs. That’s why I was so stunned when that Columbia student said peer-reviewed “facts” could speak for themselves.

Here’s another example related to the work of Harry Collins, who inspired Mooney’s column. Collins’s respect for scientific expertise stems in part from his decade-long immersion in the field of gravitational-wave studies. Gravitational waves made headlines a year ago, when astrophysicists overseeing an experiment called Background Imaging of Cosmic Extragalactic Polarization 2 announced they had discovered the “first direct evidence” of inflation, a 35-year-old theory of cosmic creation. According to the group, gravitational waves triggered by inflation had distorted the big bang’s microwave afterglow in measurable ways.

No less an authority than Stephen Hawking declared that the BICEP2 results represented a “confirmation of inflation.” I nonetheless second-guessed Hawking and the BICEP2 experts, reiterating my long-standing doubts about inflation. Guess what? Hawking and the BICEP2 team turned out to be wrong.

I’m not bragging. Okay, maybe I am, a little. But my point is that I was doing what journalists are supposed to do: question claims even if–especially if—they come from authoritative sources. A journalist who doesn’t do that isn’t a journalist. He’s a public-relations flak, helping scientists peddle their products.

And it’s precisely because we journalists are “outsiders” that we can sometimes judge a field more objectively than insiders. Mooney surely agrees with me on this. There is an enormous contradiction buried within his “No Business Challenging Scientific Experts” argument. He obviously doesn’t want us to yield to every scientific consensus, only to those that he, Mooney, deems credible.

Google is reportedly working on algorithms for evaluating the credibility of websites based on their factual content. But there will never be a foolproof way to determine a priori whether a given scientific consensus is correct or not. You have to do the hard work of digging into it and weighing its pros and cons. And anybody can do that, including me, Mooney and even Jenny McCarthy.

By the way, I think McCarthy grossly overstates the dangers of vaccines–I’m glad my kids got vaccinated–but I, too, have concerns about some vaccines.

Editorial Note: On the vaccine issue, here is a recent article of interest on Vaccine Assay Secrecy by Matthew Herder and Colleagues – Herder Vaccine assay secrecy.

Everyone has the right to challenge “scientific experts” II

(This is a follow up post from John Horgan on the topic – the original is here.)

I recently knocked science journalist Chris Mooney for asserting that “You Have No Business Challenging Scientific Experts.” Non-experts have the right and even the duty, I retorted, to question scientific experts, who often get things wrong.

Far from reconsidering his stance, Mooney doubles down on it in a Washington Post column, “The science of why you really should listen to science and experts,” that defends not just scientific experts but experts in general. Mooney ends up not boosting experts’ credibility but undermining his own.

He cites a study that found that judges and other lawyers show less ideological bias—or “identity-protective cognition”–in their application of the law than law students and lay people. Titled “Ideology’ or ‘Situation Sense’? An Experimental Investigation of Motivated Reasoning and Professional Judgment,” the study was carried out by Yale law and psychology professor Dan Kahan and five other scholars.

To my mind, the study merely shows that lawyers and judges know the law better than law students and non-lawyers. That’s reassuring, but surely it does not mean we should always trust lawyers’ legal advice, especially since lawyers so often disagree on interpretations of the law. Consider the rancor of recent debates on health care, immigration, taxes, the environment and other issues in Washington, where more than one third of current Representatives and one half of Senators have law degrees, according to The National Law Journal.

Mooney nonetheless insists that the Kahan study “fits nicely alongside a growing trend toward robustly defending and reaffirming the importance of experts.” As an example of this trend, he cites the 2005 book Expert Political Judgment by political psychologist Philip Tetlock.

Mooney’s citation of Tetlock is bizarre, because Expert Political Judgment—far from a defense of experts—is a devastating critique of them. Tetlock reports on his long-term study of 284 professional pundits, including academics, government officials and journalists, who comment on politics and related issues in scholarly journals and conferences and via mass media. Over two decades, Tetlock recorded some 28,000 predictions by the experts related to wars, elections, economic collapses and other events.

In a terrific 2005 review, “Everybody’s An Expert,” New Yorker writer Louis Menand summarizes Tetlock’s conclusions as follows:

“people who make prediction their business—people who appear as experts on television, get quoted in newspaper articles, advise governments and businesses, and participate in punditry roundtables—are no better than the rest of us. When they’re wrong, they’re rarely held accountable, and they rarely admit it, either. They insist that they were just off on timing, or blindsided by an improbable event, or almost right, or wrong for the right reasons. They have the same repertoire of self-justifications that everyone has, and are no more inclined than anyone else to revise their beliefs about the way the world works, or ought to work, just because they made a mistake. No one is paying you for your gratuitous opinions about other people, but the experts are being paid, and Tetlock claims that the better known and more frequently quoted they are, the less reliable their guesses about the future are likely to be. The accuracy of an expert’s predictions actually has an inverse relationship to his or her self-confidence, renown, and, beyond a certain point, depth of knowledge. People who follow current events by reading the papers and newsmagazines regularly can guess what is likely to happen about as accurately as the specialists whom the papers quote.”

Menand’s review is loaded with gleeful one-liners, including this one: “Human beings who spend their lives studying the state of the world, in other words, are poorer forecasters than dart-throwing monkeys.” And yet this is no laughing matter. Consider how “experts” in the government, academia and media helped enable the catastrophic U.S. wars in Afghanistan and Iraq and the economic collapse of 2008. Example: New York Times columnist Thomas Friedman, who just before the U.S. invasion of Iraq expressed the hope that it would lead to “a more accountable, progressive and democratizing regime.”

How can Mooney possibly interpret Tetlock’s book as a defense of experts? Here’s how. He seizes on Tetlock’s finding that some experts were better forecasters than others. They tended to be not what Tetlock calls “hedgehogs,” who explain the world in terms of one big unified theory, but “foxes.” Foxes, Tetlock explains, “are skeptical of grand schemes,” and “diffident about their own forecasting prowess.”

In other words, the most credible experts are those who, implicitly, warn us to be wary of experts. Mooney is oblivious to this irony. “So experts really do exist,” he blithely concludes, “and they really are different from non-experts. Now, all we have to do is listen to them.”

I prefer Menand’s conclusion. He writes that “the best lesson of Tetlock’s book may be the one that he seems most reluctant to draw: Think for yourself.”

Addendum: Listen to me talk about the need to challenge experts on New Hampshire Public Radio

From Corey Powell, old friend, distinguished science writer, former editor-in-chief of Discover, whom I quote dissing meteorologists above:

Just to be clear–my argument wasn’t that meteorologists lack the ability (or worse, the right) to challenge climate studies. My argument is that they suffer from a false sense of expertise that makes them think they can speak with authority without bothering to really understand the other field. It’s a lazy kind of arrogance. This often happens when scientists get taken with their own brilliance and think, hey, I know about genes, I’ll bet I really understand consciousness or solar energy or alien life or whatever. Of course almost everybody with a healthy ego does this to some extent, fantasizing that they are experts at something they know nothing about. But with the meteorologists (as a case study) there is a more specific type of confusion, and a more specific type of unearned claim to authority. I liked our quick Twitter exchange about the role of curiosity vs. gall. Both of them are about questioning everything, including expert testimony & peer-reviewed truths. I take a bit longer to reach full boil when I come across BS, but I get there eventually.

From Matthew C. Nisbet, Associate Professor of Communication Studies, Northeastern University:

In American political culture, liberal commentators and advocacy journalists tend to put scientists on a sacred pedestal and are often funded to do so and attract audiences by doing so.

Climate scientists especially are not only portrayed as innocent priests and powerful seers but also as vulnerable martyrs that must be protected and defended against any criticism, even when such criticism comes from social scientists or specialist journalists who are speaking from the perspective of their own expertise.

On complex, wicked problems like climate change, the only way we identify paths forward and opportunities for political cooperation is through healthy disagreement.  Criticism helps widen the menu of options that might be pursued and calls attention to faulty assumptions.

Another example of the need for informed criticism of experts, as I discussed in a recent co-authored paper, is the work of the journalist Gary Taubes who helped spur scientists to reconsider their assumptions about the linkages between diet, obesity, and other negative health outcomes.

From David Gorski, physician and blogger at “Science-Based Medicine”:

Gorski critiques my column in a post titled “On the ‘right’ to challenge a medical or scientific consensus.” Like Mooney–and like me!–Gorski has concerns about the propagation of pseudoscience, but his piece is one long exercise in begging the question. That is, he implicitly assumes what he is attempting to argue. He writes: “It’s… important to remember that there are scientific consensuses and then there are scientific consensuses. What I mean is that some consensuses are stronger than others, something Horgan seems to ignore or downplay.” The primary point of my piece is that there is often no way to know whether a consensus is legitimate or not; scientists often claim more certainty than is merited, and hence outsiders are justified in questioning scientists’ proclamations. Gorski’s own field, oncology, offers an excellent example of this problem. For decades, the consensus was that cancer should be combatted with frequent testing and aggressive treatment, but now that consensus is unraveling. “In the end,” Gorski concludes, what Horgan seems to be arguing is that we should take pseudo-expertise seriously.” Actually, I am arguing that the public should be wary not only of pseudoscientific charlatans peddling homeopathy and “energy healing” (Gorski’s examples) but also of genuine experts like Gorski.


See also my next post, “Sociologist Steve Fuller: Scientists Aren’t More Rational Than the Rest of Us”; and my Bloggingheads.tv chat with anonymous blogger “Neuroskeptic,” an expert who displays admirable skepticism toward his own field.

 Further Reading: