Tangled up in Bureaucracy flagged a Signal for the Goose Signal for the Gander as a sequel. That was before the Gary Bullivant comments on Tangled up in Bureaucracy. If you don’t normally read comments on post, the Bullivant-Kingston comments are in this link; they are worth reading. GB’s comments fit nicely in with a delicious 2019 correspondence between Dee Doherty and Louis Appleby leading to this intercalated post, which features one of Bill James’ greatest creations. Bill’s title for this – a key part of the creation – brings several layers of meaning into view. Try guessing what it is before reading more.
MHRA, NICE and LA appear to be what Harriet Vogt has called defenders of the faith or what Catholics would recognize as apologists. Catholics, boys at least, were once taught Apologetics. This does not mean saying sorry for the extermination of native populations en route to world domination. It means being able to stand your ground and explain why what the Church has done, or its view on something contested, is the rational one.
A century ago through to 50 years ago Marxists used to be good at this but as these ‘faiths’ have lost relevance the wider public are less aware of what is going on. Apologetics are deployed by politicians from Russia to Israel these days. The pharmaceutical industry are among the most skilled proponents of these ‘arts’.
After a slip-up reveals what LA really thinks – repeated off-the-record in the background of the Kingston case, several classic LA – LA Land dance-steps show in his email responses.
- Akathisia can happen, even make you feel suicidal, but we have no evidence it leads to suicide. We will settle this once we know how many angels fit on a pin-head.
- The drug may play a part but is only a possible contributory factor along with other stressors that would likely have led to suicide anyway.
- If you deviate from the script and stop your medicines without your doctor agreeing – you’ve killed yourself.
- Doctors don’t want to warn for fear of deterring people from seeking a benefit and perhaps ending up killing more people than they save by warning.
- The safety of antidepressants in suicide prevention below means – Does an overdose kill you? From this point of view SSRIs are the safest antidepressants.
- It’s the job of the doctor seeing you to work out what to do in your situation – nothing to do with a Suicide Czar, or MHRA or NICE.
- If your doctor decides the drug caused you to take your own life, that’s just their opinion, Suicide Czars, MHRA and NICE are double-blind to these things.
- Let me helpfully put you in touch with the powers that be – pass you from pillar to post (MHRA, NICE, RCGP) – who will do just pass you back and forth till you give up.
- Ask me to put my name to something – that’s not how government works.
- Support a convention where all issues can be tackled – forget it.
Dee to Louis
In 2019 Louis Appleby, Britain’s Suicide Czar, favoured a tweet from Jasna Badzak, a former UKIP press secretary, claiming that drug safety advocates enquiring about iatrogenic deaths and akathisia are nothing more than “a dangerous cult”.
Outlining that a family member had become suicidal soon after going on an SSRI, Dee Doherty emailed Louis asking if he viewed her and her family member as dangerous cultists?
Louis <Louis.Appleby@manchester.ac.uk> Mon, Sep 30, 2019
To: Deirdre Doherty
Dear Mrs Doherty
I want to let you know I’ve deleted that tweet, given your concern about it. After all, my comment on it was actually about ensuring a positive atmosphere on my timeline.
I can assure you the safety of antidepressants is seen as an important issue in suicide prevention.
Caution over suicide risk is in NICE guidance and the side effect of restlessness is referred to in the national suicide prevention strategy.
With best wishes Louis Appleby
Deirdre Mon, Sep 30, 2019
To: Louis
Dear Professor Appleby,
You caused great distress to my family and others, took no responsibility, offered no apology and did not address the issues. Can I at least be reassured that you don’t think of myself and my teen stepdaughter after her experience of missing one Sertraline pill as part of a “dangerous cult”?
More crucially, I do not understand your response on the critical issue of akathisia. This remains urgent, and for my family. The mother of my teen stepdaughter thinks I’m a Conspiracy Theorist.
The child is now withdrawing and I am very concerned after her previous experience upon missing one pill.
Can SSRIs induce death by self-harm – I ask so the teen’s mother may take it from you. I don’t want to have to keep asking this valid question. Please imagine if it were your child.
Sincerely, Deirdre Doherty
Deirdre Tue, Oct 1
To: Louis
Dear Professor Appleby
My apologies, I neglected to request where “restlessness” as a side effect appears regarding SSRIs in the Govt Suicide Prevention Strategy. Thank you and for any appreciation of our family circumstances,
Deirdre Doherty
Louis Wed, Oct 2
To: Deirdre Doherty
Dear Mrs Doherty
Thanks for replying. I want to try to answer your questions in the most helpful way, so it makes sense to start with my understanding of the main issue you have raised.
SSRI antidepressants can cause akathisia. I have seen many patients with akathisia, caused by different drugs, and it is an extremely unpleasant condition that at its most severe can make people feel desperate and suicidal.
It’s hard to estimate how often it causes suicide or self-harm, partly because what makes people suicidal is often a mixture of problems – it is rarely caused by one thing. However, the risk is sufficiently concerning for us to be cautious at all times, especially when starting or stopping treatment. It’s essential that the doctor who prescribes SSRIs should inform the patient about this risk, as you say, though I do understand that doctors don’t want to put a patient off taking treatment & getting the balanced message of risks and benefits right can be hard.
On the national suicide prevention strategy, I need to explain a little of the background. When we came to update the strategy a few years ago, the Government wanted as few changes as possible. We were keen to add something about antidepressants after hearing from families who felt strongly about this and we thought it was best done in the section on treatment of depression in primary care which was mainly about the risks of getting no treatment. So we added a line to the key messages of this section, as follows:
“There are also risks in the early stages of drug treatment when some patients feel more agitated.” (page 27).
This may not sound a lot but at the time it seemed an important and unusual acknowledgement to appear in a Government strategy. We used “agitated” because it was a document for the general public rather than clinical guidance for doctors – that’s the job of NICE – or information for patients, which is overseen by the regulator, the MHRA. Current NICE guidance says something more specific about the need for careful monitoring in the early period of treatment, especially in younger people, because of suicide risk.
I’m sorry to hear about the difficulties your step-daughter has faced. If she has had severe akathisia on withdrawal, it’s an important point of safety to withdraw more slowly, to avoid the distress I’ve mentioned. Most people can come off antidepressants if it’s done over the right time period, and that can vary for different people.
I hope I’ve answered what you were asking about your step-daughter but if I’ve misunderstood please feel able to come back to me. Of course, I’ve “unblocked” you – happy to do this – but being in touch by email is a lot better than twitter.
With best wishes Louis
Rubber Hits Road
Deirdre Fri, Oct 4, 2019
To: Louis
Dear Prof. Appleby,
From what I can understand, as akathisia is an adverse drug effect of so many increasingly prescribed medications and as suicide rates may be reduced with greater awareness both of the signs of suicide and of the signs of akathisia, would you kindly support an Informed Consent & Patient Safety petition regarding the material risk of akathisia?
The petition would go something like this:
We, the undersigned, were aghast to learn via recent communication with Prof. Louis Appleby, a UK Suicide Prevention expert, that the government are restricting safety information in suicide prevention strategies. We find this incomprehensible, given the admittance by Prof. Appleby that “SSRI antidepressants can cause akathisia.” Adding further, “it is an extremely unpleasant condition that at its most severe can make people feel desperate and suicidal.”
Do we have your backing on this, Prof. Appleby? Thanks for taking this very seriously,
Deirdre Doherty
Louis Wed, Oct 9
To: Deirdre Doherty
Dear Mrs Doherty
I’m approaching this in a slightly different way but I hope it’s helpful.
The problem of petitioning the Government is that they will see this as a clinical issue, something that falls within NICE’s independent remit. I think it would be better to go direct to NICE – they are the main source of guidance to GPs and other health professionals. I’ve been in touch with them about the best way for you to do this, as they are still working on their depression guideline.
NICE depression guidance currently advises careful monitoring when people, especially young people, first start antidepressants because of suicide risk but it doesn’t link this risk to agitation or akathisia. The depression guidance for children & adolescents, 18 & younger, is very cautious about the use of antidepressants at all and stresses the importance of patients being fully informed, and keeping a written record of this.
Given the points you’ve raised with me, your request to NICE could be that (1) it could include a reference to agitation/akathisia as a warning sign of suicide risk (2) the recording of informed consent could be extended to cover young adults in the adult guidance.
One way to do this is to write to NICE at this email, either personally or via any organisation you work with, to say that you want to provide information about safety DepressionInAdultsUpdate@nice.org.uk
It may sound a bit bureaucratic but all this is part of NICE being strictly independent, doing everything by the book. If you find you aren’t getting the right response, come back to me & I’ll contact them again.
With best wishes Louis
Louis Thu, Oct 10
To: Deirdre Doherty
Dear Mrs Doherty
I meant to add that the other way to approach this is via the Royal College of General Practitioners who oversee training for GPs. They are the main prescribers of SSRIs and getting your messages into their training would reach a lot of people. Let me know if you want to follow this up.
I’m conscious this is taking you into the way the various national health care bodies work & that can seem complicated if it is unfamiliar. Come back to me if you want me to clarify any of this.
With best wishes Louis Appleby
Deirdre Thu, Oct 10
To: Louis
Dear Professor Appleby
Thank you for all these different suggestions to follow up. Yes, I am understandably confused about how these different processes work but I’m happy you will help me help others be more aware of the suicide risks related to akathisia. My family was left in the dark and we are lucky we survived akathisia at its worst.
It’s not good for me or our efforts that I appear like a lone wolf in wanting to clearly communicate akathisia and the big differences between akathisia and agitation. I would feel more comfortable following up on your suggestions if I can talk with someone who is already familiar with your previous efforts to add akathisia to the national suicide prevention strategy. Can you please give me the names and contact info of those who you previously spoke with when you tried to make these changes so I can also seek their support?
Akathisia awareness has increased since you last worked with the government to add akathisia info and related suicide risks to the national strategy. I don’t think the word akathisia should continue to be left out because of some out-dated, false assumption that it is too clinical a word for families to understand. I will do my best to work with you and other professionals in this field to make these needed changes to the national strategy, to NICE and to all doctors’ training. Other families need to be better informed than my family was.
I feel sorry that you’ve received so much negative flak on Twitter given that I now know you made previous efforts to include akathisia risks in the national strategy. I think the best way forward is to petition the government and include the dilemmas you faced when trying to improve suicide prevention strategy. If the public can see the government are not supporting a suicide prevention expert, more people will probably support a petition. Also, since I’m still suffering from adverse drug effects, I’m hopeful a petition will bring new people with different skills who can work with us towards these goals.
Best wishes, Deirdre Doherty
Louis Thu, Oct 17,
To: Deirdre Doherty
Dear Mrs Doherty
Sorry not to reply before now, I’ve been away.
To clarify, the Government doesn’t make decisions about clinical practice or training. It delegates these issues to expert bodies that are independent and have the necessary expertise. NICE are the body that puts out clinical guidance to health professionals. Royal Colleges oversee training. These are the organisations that can change practice in the way you want.
It was quite unusual for the national strategy to include a specific clinical point. In that sense the Dept of Health supported me, it wouldn’t be correct to suggest otherwise. A national strategy is an overall statement about the importance of an issue such as suicide prevention, intended to support and inform the NHS, local authorities, etc. It doesn’t instruct them on what to do – that is decided in each local area.
I can see you would like to influence the Government on the issue of akathisia but their response is likely to be that this is the role of NICE. Of course, it’s your decision how to proceed – I’m just concerned you could put a lot of effort into pursuing this in a way that would, in the end, be frustrating for you.
In the meantime, I’ll assume you want me to approach the RCGP, as I mentioned in my previous email, and I’ll now do this.
With best wishes Louis Appleby
Deirdre Thu, Oct 17
To: Louis
Dear Professor Appleby,
I will organise the Petition with my original wording.
Can you confirm in writing that you support the Petition or are you now saying the Government never imposed restrictions? I’m confused.
We, the undersigned, were aghast to learn via recent communication with Prof. Louis Appleby, a UK Suicide Prevention expert, that the Government are restricting Safety Information in Suicide Prevention strategies. We find this incomprehensible, given the admittance by Prof. Appleby that “SSRI antidepressants can cause akathisia.” Adding further, “it is an extremely unpleasant condition that at its most severe can make people feel desperate and suicidal.”
We learned that the Suicide Strategy Plan is severely lacking in concise information. Prof Appleby, via correspondence, told us, “When we came to update the strategy a few years ago, the Government wanted as few changes as possible.”
We urge the Government to rethink their stance and demand to know why they feel few changes are needed.
Best wishes, Deirdre Doherty
Louis Sun, Oct 20
To: Deirdre Doherty
Dear Mrs Doherty
I’m very willing to help but there’s a misunderstanding here about the role of the Government. It might help if I explained a bit more.
The Government at that time had a policy of supporting local independence, so it wasn’t keen on national strategies which were seen as “top-down”, ie telling local people what their priorities should be. We did get agreement to relaunch the national suicide prevention strategy but it had to be an update, not a new strategy.
It’s very important to know what a strategy like this is for. It is a broad statement of how we should approach a problem, it is not a detailed list of actions that people should take. Organisations like the NHS or local government are expected to respond by providing the detail for their staff. It isn’t the role of the national strategy to issue clinical advice to doctors – that is for NICE or the regulator, the MHRA.
So the Government did not restrict safety advice or fail to support me. In fact, it went beyond its remit by allowing me to refer to the risk on starting treatment for depression after people had raised this with me. I told you about this so that you would know that their concerns, which are similar to yours, were not ignored.
My advice is to focus on what matters most to you, the problem of akathisia and the importance of informed consent, where you are making a powerful point. The main issue could get lost if the petition is about the Government.
Of course, it’s your decision. The help I can give is more about how to get through to the organisations that actually influence prescribing practice, such as NICE and the Royal Colleges. I can also advise you on how our complex health system works – I do understand it must seem confusing.
With best wishes Louis Appleby
Signal for the Goose will follow in a few days.
Double-Blind Cure © Billiam James 2020
Dee Doherty deserves the Jeremy Paxman – ‘why is this bastard lying to me’ – award. Paxo’s famously ferocious interviewing inspiration, though he didn’t originate the phrase.
The LA-LA Land twirls she teased out were the stuff of satire – think Green Wing goes Public Health – not the stuff of suicide.
In search of something slightly more serious, I re-read the ‘Suicide prevention in England: 5-year cross-sector strategy’: https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy
It’s like so many public health strategy documents, a macro framework of the obvious. People who are so desperate they take their own lives – tend to show evidence of isolation and social adversity, many have a history of self-harm, alcohol and (illict) drug misuse is common, a significant minority experience serious financial problems, domestic abuse, physical illness etc. etc. Obvious, but no less tragic. Ironic that the governments who commission these strategic frameworks are themselves mostly responsible for the social policies that cause many of the problems.
The document has some obvious and perfectly sensible recommendations – like ensuring no accessible ligature points in inpatient ‘mental health’ settings (you might have hoped someone would have thought of that), and funding suicide education programmes through VSCE (voluntary, community and social enterprise) organisations. But it all feels extrinsic – like circumstantial evidence – where’s the insight? It’s no good just talking about suicide, the need is to prevent it.
Reading mostly between the lines of the official document reveals some clues. Just over a quarter of suicides were patients receiving ‘mental health care’. The report notes that 22% missed their last contact with services and 12% were non-adherent with drug treatment. But, hang on, that means 78% had engaged with their last appointment and 88% were adherent with drug treatment. What this says to me is that – social and personal circumstances are making these individuals’ lives unsurvivable- but the ‘mental health’ care they are receiving- including medication – is not working to ameliorate their insufferable state of being.
What’s more – ‘nearly half had been contact with services in the week before death. AT THE FINAL SERVICE CONTACT, THE IMMEDIATE RISK OF SUICIDE WAS VIEWED AS NOT PRESENT OR LOW IN THE MAJORITY OF PATIENTS’.
I came across an insightful study – a qualitative ‘conversation analysis’ of 319 recorded outpatient visits. The key finding, ‘Psychiatrists tend to ask patients to confirm they are not suicidal using negative questions. Negatively phrased questions bias patients’ responses towards reporting no suicidal ideation.’
Nobody wants their patient to kill themselves. Suicide is notoriously hard to predict. But it seems not unreasonable to expect a more subtle, open and person-centric conversation.
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1212-7
Looking at those who suicide and are in contact with primary care showed that desperate people seek help from their GP increasingly desperately. Their needs are escalating. No surprise. https://bjgp.org/content/74/744/e426
And, from another study:
‘Males who saw a GP recently were more likely to have been prescribed a selective serotonin reuptake inhibitor (SSRI)/serotonin– noradrenaline reuptake inhibitor (SNRI) type antidepressant, oral antipsychotic, benzodiazepine, or other psychotropic medication by a GP, mental health, or emergency department clinician ‘.https://pmc.ncbi.nlm.nih.gov/articles/PMC10170520//
There is limitless individual complexity to the social, emotional and physical pressures that drive a human being to take their own lives. But there is clear evidence of pinpointable moments when their lives might conceivably be saved. If only more doctors could listen with extrasensory sensitivity. If only they understood that the pills they prescribe in the hope of saving a life are more likely to take one. If only Dr Morgan has known that the 50mg of sertraline that made Tom Kingston unbearably anxious was not a low dose, that citalopram is the same class of drug likely to have the same potentially disastrous effects.
I had a friend on twitter, as it then was. An extremely bright, amusing and talented young woman, whose PhD was interrupted by difficult personal circumstances and no reasonable adjustments from her university. After trying to tough it out, she turned to ‘mental health services’ for help and was, not resisted by her, poly-drugged – but neither understood nor truly supported.
These were her last desperate tweets before she took her own life:
‘Reach out if you’re struggling with your mental health’, they said. ‘Ask for help’, they said. I’m exhausted. I have been reaching out (for current episode) since 2019. I am worse now. I am really exhausted and pretty suicidal. I spoke to 111 for 90 minutes. I am alone again.
I am completely exhausted and fed up and idk what to do with myself. I don’t understand a system that leaves suicidal people alone, but what the fuck do I know. I was honest with 111. I guess it’s up to me to try to manage yet another MH crisis, as well as be a gynaecologist.’
If services want to learn how to prevent suicide, listen to her.
RIP R.
H
You touch on several important points that Dan Johnson or Yoko Motohama and Vincent Schmitt could almost certainly add to. In both cases certainly Dexter’s and many others the doctor as you say says something like “You aren’t going to commit suicide are you” to which the persons says No I’m not which means Not this minute. The doctor then writes in the notes that the patient has contracted not to commit suicide.
This is all done on the advice of the doctors medical insurance and aims at covering the doctors back – the patient contracted not to kill themselves – what can I do if they break their contract”. Nothing to do with the safety of the patient – in fact it probably makes things less safe for the patient.
If the patient has attempted self-harm etc after going on an SSRI which clinical trials show is more common treatment that not = even if they have never self-harmed before in their life, they are all too likely to be diagnosed with a personality disorder. This is horrific. Worse again, the Tik-Tox generation now glories in Emotionally Unstable Personality labels. And Appleby’s records link suicides to personality disorders.
D
H
A second reply to you and Dee.
The MHRA, Louis and Suicide Prevention Strategies deal in information bits not people. MHRA remove names and keep Yellow Cards piling up – should that be pilling up – hoping at some point in the dead of night when they are all at home asleep some Elf will come out and make something decent of the scraps for them.
They have no sense that contacting Dee or anyone in this position like the Kingston’s is the way understand what the problem and put it right
D
I think your ‘bits’ insight is fundamental.
Linear shopping lists of rating scales and ‘side effects’, and the fractured complexity of NICE guidance, bears no relation whatsoever to the experiences of any human being any of us have ever met – iatrogenically harmed or not.
Only whole individual narratives – Dee’s, Romain’s, Dexter’s, Tom Kingston’s, Charlie Brown’s and so many more – make sense of risk – and outrage. Presumably atomising risk is deliberate.
This is also highly relevant to Mary and Shane’s withdrawal support group. I spent another evening with them last week. The gap between what they are experiencing and trying to put into words to their doctors vs the scope of RCT/PIL/guidance led clinical language and concepts – seems to be unbridgeable. A void. I’ve bet you’ve written about this.
I believe that the following quotation is attributed to Theodore Roosevelt:
One of our defects as a nation is a tendency to use what have been called “weasel words”.
It seems relevant to this post.
Tim
It is indeed. The UK equivalent is Robert Armstrong’s Being Economical with the Truth from the 1986 Spycatcher Trial.
David
“To clarify, the Government doesn’t make decisions about clinical practice or training. ”
And yet
“On the national suicide prevention strategy, I need to explain a little of the background. When we came to update the strategy a few years ago, the Government wanted as few changes as possible.”
I think you hit the nail on the head with the apologetics; it really is like dealing with the Catholic Church. It’s a strange compulsion to omit akathisia from suicide prevention guidelines. I’ve been reading a lot of essays on Substack recently, and the compulsion toward apologetics is one of the worst tendencies in the profession—the mental gymnastics of it all. The flowery language, the long-winded polemics… it’s exhausting. Perhaps by design. Someone needs to come along and beat them over the head with some Hemingway.
What’s bizarre is that, in these apologetics, they always begin by acknowledging the truth of the problem—often saying, just like an LA has, that they’ve seen it in their own practice. Yet, somehow, they twist and contort it so that by the end, they’re arguing, “Well, you know, science says that, scientifically speaking, the data shows that the rating scale and, you know, in practice you can’t avoid all risk, and depression carries a statistical risk of suicide.” That’s what it always boils down to after a long, circuitous route: statistically, the “average depressed person” is better off taking the drug—even if the difference can only be measured by the phallic appendage of a bumblebee. And this is despite their own clinical observations that, in individual cases, these drugs can dramatically increase suicide attempts.
They will cling to the two patients they know who did well on antidepressants, even as they admit to having quite a few others become agitated. It’s all lies, damned lies, and statistics. Even Blind Freddy can see the problem. Why does the profession insist on depleting the Amazon rainforest’s paper supply before admitting that perhaps humans can’t levitate?
Mind you, the other side engages in the same base rhetoric; this blog is the last remaining refuge of good sense. It’s the inability to hold multiple truths, which aren’t in contradiction, simultaneously. They, for some daft reason, see a contradiction and drive madly toward a one-size-fits-all answer. Not to mention the talking past one another. I saw a back-and-forth the other day between two such apologists commenting on another psychiatrist who has been prominently critical of various drugs, saying that he wasn’t critical enough. So they flip-flop, and so does the other side, and yet objective reality is out there.
The sticking point is something else—something to do with egg on the face. The truth is inconvenient to both extremes, and so the “middle ground” gets played up in the rhetoric. It’s like the olive branch, but it’s always some middle that’s positioned for convenience, not precisely real life. All to avoid the simplest empirical observation, which would state: “Antidepressants cause suicidal behavior in a not-insignificant number of people.”
And like any other good clinical observation, on which the entire profession is based, this should be included in training and be part of what is generally known about the subject and disseminated. Why exclude such a fact and single it out for special secrecy? Just as the Church is morally against certain matters, and yet singles those same matters out for special secrecy.
Little doubt that as a psychiatrist throughout his career Louis Appleby has by prescription, coercing and force medicating’ caused akathisia:
“SSRI antidepressants can cause akathisia. I have seen many patients with akathisia, caused by different drugs, and it is an extremely unpleasant condition that at its most severe can make people feel desperate and suicidal.”
I wonder how he, in his view, treated these people and I’d like to hear from what his patients experience was of his treatment.
Suspect we’re going to get an unraveling of the truth when assisted death is rolled out with akathisia patients demanding their life be ended and cases go to court.
“Antidepressants cause suicidal behavior in a not-insignificant number of people.”
Just to further qualify that from the former Medical Director of the Zoloft Product Strategy Team at Pfizer:
“One drug company scientist, Dr. Roger Lane, who, until early 2001, was the Medical Director of the Zoloft Product Strategy Team at Pfizer wrote two peer-reviewed articles on the subject of SSRI-induced akathisia. The first article, published in 1995 and co-authored with Dr. Sheldon Preskorn, is entitled: “The SSRIs: advantages, disadvantages and differences.” Beginning at page 168 of the article, Dr. Lane states:
“The SSRIs may influence dopamine neurone firing in the substantia nigra through their effects on serotonin input to this nucleus. Therefore they can cause extrapyramidal side effects (Baldwin, Fineberg and Montgomery, 1991). The most common are akathisia.”
Some background here. Pfizer had lots of reports of problems like this. They were looking at several different ways to manage their problem – not our problem. Roger Lane went out of his way to avoid talking to or engaging with me. But did not go out of his way to avoid collecting ‘dirt’ on Healy.
Pfizer appear to have let Lane shortly after this – which meant among other things that lawyers for defendants could not require him to testify under oath in cases involved sertraline.
D
There seems to be a complete ‘NOGO’ around antidepressants (especially) and Akathisia/suicide.
This Holeousia post (to which I contributed) sums up some background.
SEE ALSO the astonishing communication shared within the ‘replies/comments’…
This took place just as the Covid situation kicked off, 5 yrs ago….
https://holeousia.com/in-the-world/a-sunshine-act-for-scotland/pe01651-prescribed-drug-dependence-and-withdrawal/a-timeline-of-missed-opportunities/
Marion
Which bit in particular do you mean? There is no section called replies as such. There is a bunch of links – is there one or two that stand out for you.
David
When I use this link on my laptop – I can see 22 replies …
Comprising correspondence with various orgs on the matter …
https://holeousia.com/2020/01/15/a-timeline-of-missed-opportunities/
If you mean links to related interesting material rather than replies, there are a number of these – which are interesting. Dr Appleby features several times but never mentions the role that antidepressants might play in causing suicide. He mentions that the medial have a responsibility in this are – which appears to mean that they should never link a suicide to a medicine
D
Including this logged letter
Marion Brown says:5 years ago
Reply
I have today submitted – on behalf of the group of us who wrote the 3 March2020 ‘Open Letter’ – a response to the reply we received from the UK Department of Health and social Care on 1 April 2020:
TO: Ministerial Correspondence and Public Enquiries
UK Department of Health and Social Care 1 May 2020
Your Ref: DE-1208072
Thank you for your letter of 1 April 2020, in response to our Open letter of 3 March.
“UK NATIONAL SUICIDE PREVENTION STRATEGY: SSRIs/SNRIs and AKATHISIA risks”
Your response [see in Replies above] does indeed contain links that would indicate that the significant suicide risks of SSRI & SNRI antidepressants are recognised by MHRA, NICE and BNF, and that prescribers are cognisant of these – in the context of ‘treatment for depression’. Even so, in the ‘treatment for depression’ context the suicide risks are effectively ‘played down’, claiming that ‘benefits outweigh risks’, which tends to be what prescribers ‘hear’. Busy and overwhelmed GP prescribers are effectively unable to ‘monitor closely’ for ensuing suicidality those patients (of any age) who they start on antidepressants, and at times of dose &/or medication changes.
The facts (known suicide risks of antidepressants – including risks of medication-induced akathisia) are nevertheless completely omitted from the National Suicide Prevention Strategy. This is a very serious and significant omission – and is what we are red-flagging.
Please see this: https://www.researchgate.net/publication/331536346_Problematic_Advice_From_Suicide_Prevention_Experts
Based on a 10-year systematic review of suicide prevention strategies, “29 suicide prevention experts from 17 European countries” recommend 4 allegedly evidence-based strategies to be included in national suicide prevention programs. One of the recommended strategies is pharmacological treatment of depression. This recommendation is problematic for several reasons. First, it is based on a biased selection and interpretation of available evidence. Second, the authors have failed to take into consideration the widespread corruption in the research on antidepressants. Third, the many and serious side effects of antidepressants are not considered. Thus, the recommendation may have deleterious consequences for countless numbers of people, and, in fact, contribute to an increase in the suicide rate rather than a decrease.
Please ensure that this is matter is properly addressed at this time when the National Suicide Prevention Strategy is being revisited in the context of the Covid-19 Pandemic, as reported in HSJ 23 April 2020, and also topic of Lancet Article 21 April 2020.
https://www.hsj.co.uk/coronavirus/unprecedented-plan-to-prevent-suicides-during-covid-19-crisis/7027431.article
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30171-1/fulltext
Thank you
Marion Brown, Stevie Lewis, Beverley Thorpe Thomson, Millie Kieve, Catherine Clarke, Peter Gordon, Jo Watson, John Read, Peter Gotszche, Janette Robb, James Moore, Bob Fiddaman, Dierdre Doherty, Kristina Gehrki, Fiona French, Alyne Duthie
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Response Today – 7 October 2020 – to our email of 1 May 2020
Department of Health and Social Care 2:34 PM
Our ref: DE-1222649
Dear Mrs Brown,
Thank you for your further correspondence of 1 May about the UK National Suicide Prevention Strategy. I have been asked to reply and apologise for the delay in doing so.
I note your continuing concerns.
As you know, in January 2019, the first Cross-Government Suicide Prevention Workplan was published, which sets out an ambitious programme across national and local government and the NHS. It will see every local authority, mental health trust and prison in the country implementing suicide prevention policies.
The Government has made further investment of £1.8million to support the Samaritans helpline and £2million across 2019/20 and 2020/21 for the Zero Suicide Alliance, which aims to achieve zero suicides across the NHS and in local communities by improved suicide awareness and prevention training and developing a better culture of learning from deaths by suicide across the NHS.
The COVID-19 outbreak is the biggest public health emergency in a generation and it calls for decisive action, at home and abroad, of the kind not normally seen in peacetime. The Government recognises that measures such as social distancing, self-isolation and shielding are likely to increase the risk of loneliness and mental health issues, particularly for vulnerable people affected by COVID-19, and it needs to be well prepared for this increase.
The Government’s strategic approach has been to increase mental health knowledge and understanding and encourage individuals to engage in behaviours that protect their mental wellbeing throughout this challenging period. To support this, it has published official guidance on mental health and wellbeing and promoted this through trusted channels like http://www.gov.uk and Every Mind Matters.
Throughout the pandemic, mental health services have remained open and are working to support people with mental health problems throughout the pandemic and beyond, delivering support digitally and over the phone where possible.
The Government and the NHS are working closely with mental health trusts to ensure those who need support have access to mental health services. The NHS has issued guidance to services to support them in managing demand and capacity across inpatient and community mental health services and keeping services open for business and, for those with severe needs or in crisis, NHS England and NHS Improvement has instructed all NHS mental health trusts to establish 24-hour mental health crisis lines, clearly accessible from trust websites.
The Government recognises the vital role played by mental health charities and the voluntary sector in providing direct support for mental health and wellbeing alongside the NHS. It has already provided £5million to mental health charities to support their work during the pandemic and on 22 May, it announced that a further £4.2million will be awarded to mental health charities, such as the Samaritans, Young Minds and Bipolar UK, to continue to support people experiencing mental health challenges throughout the outbreak.
I hope this reply is helpful
Yours sincerely,
Leigh Smale
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care
Marion
There are some real gems here. The Carmine Pariente stuff is awful – part of what is so awful is that it has become so normalized that it is likely very difficult for most people to get to grips with why it is such a problem.
The submission from Millie Kieve (APRIL) is revealing.
38. Director of Suicide Prevention & Mental Health, Professor Louis Appleby, while assuring me personally that he would address the situation, has not included in his Suicide Prevention Strategy any warnings about akathisia or other drug- induced psychiatric adverse effects.
David
Following the material Marion posted including LA’s ‘Steady the Buffs’ political video, and bearing in mind the Paxo watchword, ‘why is this bastard lying to me?’ – I’ve been doing a little research.
It didn’t take long to turn up this Indie piece – revealing the true extent of human desperation and service chaos underlying the buffs steadying:
‘’Exclusive: NHS figures leaked by whistleblower suggest more than 15,000 patients died in care of community mental health services in just one year – with desperate families forced to ‘beg’ for treatment from overstretched medical teams.
The leaked report reveals that:
• At least 137 women died between 2022 and 2023 while under the care of services for pregnant women at one unnamed trust
• Nearly one in 10 of the patients treated by a crisis service – designed to help those with the most severe mental health conditions – died while under that care
• One unnamed mental health trust recorded more than 500 deaths in that year-long period
The report reveals that, across the country, an average of 127 patients per 10,000 died while under the care of all community mental health teams in 2022-23. The Independent estimates that this equates to more than 15,000 deaths among the 1.2 million patients cared for by those teams.”
https://www.independent.co.uk/news/health/nhs-mental-health-deaths-leak-b2526944.html
This dovetails with the despair sounded by patients and families on X. And by my late twitter friend, R, whose narrative is a tragic classic (Caps are my edit):
‘Why can a psychiatrist diagnose me with a PERSONALITY DISORDER as soon as look at me, but no one can diagnosis PMDD when I’m sat in front of them with 9 months worth of graphs’.
‘Feeling FRUSTRATED ABOUT THE WHOLE MEDICATION SITUATION. Unsure about what psychiatrist thinks will help, or if she even thinks anything will help. Unsure if there is genuinely the expectation that I wait until December to start lamotrigine’.
‘It’s not as if I can ‘just’ stop taking venlafaxine in any sort of haste, so this is silly thinking, but I just hate all of this so much. Don’t feel like people are working with me and that MAKES IT ALL FEEL OUT OF MY CONTROL.’
To repeat what R tweeted just before she actually took her own life:
‘I don’t understand a system that leaves suicidal people alone, but what the fuck do I know’.
This is the point. CMHS, for various possible reasons – underfunding, understaffing, lack of coordinated teamwork, heavy handed reliance on medication, disconnection from the whole person-patient – is failing to give what distressed human beings need – the safety of a sustained psychological embrace. They’re left on their own. And it’s more than they can bear.
It’s no coincidence that the admission is made in the most recent England suicide prevention strategy that suicide rates have been increasing in the under 25s over the last decade, especially amongst young women. (<25) https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy
This disturbing phenomenon is found across many countries: But, interestingly, Denmark seems to have reversed the trend – by focused social and psychological interventions – and drug regulation:
‘The temporal increases in incidence rates of self-harm among adolescents observed in some Western European countries experiencing major economic recession were not observed in Denmark. Restrictions to sales of analgesics, access to dedicated suicide prevention clinics, higher levels of social spending and a stronger welfare system may have protected potentially vulnerable adolescents from the increases seen in other countries
Denmark has also taken steps to regulate sales of common painkillers to under-18s. In many parts of the world, including the UK, there’s been a sharp rise in the number of young adults who have overdosed on painkillers and antidepressants.'
https://link.springer.com/article/10.1007/s00127-019-01794-8
The set of links Marion sent do have gems in them. There is one of Carmine Parienta (CP) giving the PC same “ADs save lives” message. Against a backdrop of this and LA living in LA-LA Land it’s easy to see why the media are cowed into not making space for an alternate message.
D
I should have added – the comment was great but the safety of a sustained psychological embrace was like going over a speed-bump too quickly It fits straight into the LA-LA-CP-PC narrative.
What happens in practice is therapists are quick to refer people who aren’t getting well to docs to be put on meds to help or seeing people get worse refer them for additional meds or dose increases.
A sustained psychological embrace has become a disaster. Especially if the therapist is not willing to agree with you the drug is causing problems and to go with you to support you in telling the prescriber this. We need common sense and human decency. F… therapy.
D
I totally agree with you.
‘Psychological embrace’ is a mushy set of words. I wasn’t thinking therapy specifically. More simply sustained care from someone/anyone who listens and understands you. Decency feels in the same zone. Having seen services imagine that CBT was an appropriate intervention for screaming withdrawal misdiagnosed as psychosis.,it’s hard not to feel somewhat jaundiced about the system’s interpretation of a sustained psychological embrace!
What you describe is exactly what happened to R. Once she exposed her despair to the system – ‘care’ was a crapshoot. Sometimes she’d hit a therapist who understood – briefly – then pass the parcel to another who was alienating. Drugs rained down on her chaotically. She was articulate about their effects – but those doing the drugging seemed neither to listen nor know what they were doing. Shades of Dr Morgan and how many well-intentioned others?
R sought support from what used to be known as ‘madtwitter’ – mostly comprised of youngish women like her, including one very supportive clin psych who identifies and fights for her team – politically. They are a genuinely loving community – but outright criticism of drugs is verboten. Compare and contrast re their effects is allowed and R did a lot of that, trying to make sense of what was being done to her.
As an unmad outsider who connected with her often in private about the other aspects of her academic/professional life – shared love of doggos , her art etc. – I could see she was likely doomed by the drugging, including venlafaxine and mirtazapine together. I’d seen research showing each one – on its own – and trazodone – had a stronger association with suicide than antidepressant ‘treatments’.
‘Mirtazapine, venlafaxine, and trazodone were associated with the highest rates of suicide and attempted suicide or self harm, but the number of suicide events was small leading to imprecise estimates.’
https://pubmed.ncbi.nlm.nih.gov/25693810/
‘Antidepresssants save lives’. Really, Carmine? Prove it.
R’s story maps onto so so many. We need to get to grips with what is keeping the lunacy going?
D
“The figures include any patient who was receiving care from a general community mental health team, while data suggests that the number of deaths would be far higher if patients receiving care from a crisis team or a perinatal mental health team, or early intervention care from a psychosis team, were included. The figures include deaths by suicide, cases in which an inquest could not reach a ruling of suicide, and those where a person has unexpectedly died, for instance from a heart attack, a stroke, or an accident.”
I’d love to have more specific details on this: which areas, who the whistleblower is and if they have more recent or earlier data. Plus a look at specific cases..the circumstance the medication and trajectory from GP. I can only hope the whistleblower brings more information forward.
Coda
This is a very relevant piece. Though I’m not convinced Wes has a clue about anything, except reducing costs. Removing one layer of bureaucracy won’t change an embedded culture. Patients are our best hope.
‘Many of the patient safety scandals that I have covered – the deaths of people with learning disabilities and mental health problems at Southern Health, maternity failures in Shrewsbury and Telford, East Kent and Nottingham – were only revealed after the skilled and active campaigning of grieving and committed families, who felt compelled to turn to the media when other efforts had failed.
“Throughout the whole of the health service, we’ve totally lost empathy for the patient. We’ve become very regimented – we need to focus on how we can help, rather than whether someone fits into a framework of how the NHS delivers care.”
https://www.bbc.co.uk/news/articles/c984qg7y4gro
David,
Thanks for another important blog post., including the interesting contributions in comments.
Like many others I have tried to engage with National Suicide Prevention programmes/Initiatives but have found when I have raised medication-related suicidality and akathisia that the ‘conversation’ closes down.
My experience of Professor Sir Louis Appleby, as a National Lead for Suicide Prevention, has not been great.
This material may be of interest:
https://holeousia.com/tag/louis-appleby/
I should make clear that it is my view that the matters involved [essentially willful blindness] apply across worldwide suicide prevention initiatives.
aye Peter
Peter
I am sure you’re right about the willful blindness applying across the developed world at least. I guess this links to Evidence Based Medicine – as everyone in every developed where claims to do – means oddly that we based our policies on company studies which are assays made of Hearsay that does not reach legal of scientific standards for evidence, whereas the evidence from people who, unlike Tom Kingston have treatment induced problems just like his but survive, are available to be examined and cross-examined as befits evidence, are ignored.
David
“There are also risks in the early stages of drug treatment when some patients feel more agitated.”
how is that an anyway fair description of akathisia? a person who was involved in a minor car accident or just had a heated argument with their spouse might feel ‘agitated’ but those experiences have very little in common with akathisia. the explanation he gives is that they had to use regular words to describe that phenomenon since this was a document for the lay public but in that case they had to have used even stronger words because as he admits it, akathisia can be very uncomfortable and painful. by comparison, agitation is not even necessarily uncomfortable. most people would surely gloss over that warning pretty quickly. this is similar to substituting suicidal ideation for “emotional lability”. some words have a strong and immediate effect and that is for a good reason. how are you going to prevent people from taking their lives when you can’t even pronounce those strong words when they are called for?
but why do they eschew those words and construct a soft and uncertain language for themselves? It is not a character flaw. They have to do that because they need to renconcile two separate goals which are in reality irreconcilable: seeming as paragons of science but at the same time protecting the current configuration of medical hegemony. psychotropic drugs have a very crucial role in today’s world, specifically in the sphere of reproduction. reproduction is the ability to regenerate the capacity for work. this actually goes both ways, as labour power to produce but also as the ability and the desire to consume. in this way psychiatric industry is the enabler of almost all other industries and it keeps the whole structure still somewhat intact. but the problem is, these drugs also reduce the population’s overall capacity to produce, consume and pleasure. that is the reason for psychiatry’s current crisis and the contradictions are deepening.
“Marxists used to be good at this but as these ‘faiths’ have lost relevance the wider public are less aware of what is going on. ” marxism is not a “faith” and you don’t have to be strictly a marxist to use the insights and methods they came up with over a century. in fact there is no other way to comprehend the whole picture and also figure out solutions without the help of a critical political economy of medicine. I agree that socialists have been a little amiss on these sorts of subjects but the more they turn their critical eye towards medicine in general and psychiatry in particular, more we’ll see interesting ideas and discoveries. a rare and good example is joanna moncrieff’s article: https://www.researchgate.net/publication/357901851_The_Political_Economy_of_the_Mental_Health_System_A_Marxist_Analysis
This was a powerful and eye-opening read. The way Dr. Healy highlights the deflection and lack of accountability in mental health systems is both troubling and important. Thank you for shedding light on voices that are too often ignored.