Model Doctors?

Another inquest may bring out the risks to doctors from their professional associations behaving as the American Psychiatric Association (APA) or the Irish College of Psychiatry has done (see Professional suicide – the Clancy case).

She posed no suicide risk. She was put on citalopram

Yvonne Woodley, a 42-year-old woman with two young daughters, ran into difficulties with her husband. They began talking of separation. Under stress, she visited her primary care doctor who noted that she was not depressed, and that she posed no suicide risk. She was put on 10mg of citalopram.

A week later she was noted by the doctor who saw her to be more anxious and for the first time as having voiced thoughts of harming herself, but she was still viewed as being at no risk of suicide. The dose of citalopram was increased after which she talked about suicidal impulses to her mother and made a suicide gesture — taking 100 analgesics to a remote place from which she phoned her husband and told him she was thinking about overdosing. He came to get her, brought her to the doctors, and from there she was referred to a mental health team.

Yvonne hung herself with her daughters downstairs watching television

A further assessment concluded that she was at minimal or no risk of suicide. She dropped her contact with the mental health team and went back to her primary care doctor who doubled the dose of citalopram yet again. A few days later, Yvonne hung herself in the attic of her house with her daughters downstairs watching television.

Lundbeck, the makers of citalopram in Europe, sent a former medical director from their UK division to the inquest, Dr Chris Muldoon. The coroner, Aiden Cotter (AC), heard testimony from the family, from me, from Chris Muldoon, from one of the primary care doctors, and from the consultant psychiatrist linked to the mental health team.

Each of the doctors was asked two questions in common: “Can citalopram cause someone to commit suicide?” and “Did it cause Yvonne Woodley to commit suicide?” I answered that it can cause suicide and that Yvonne Woodley’s case bore the classic fingerprint of a treatment-induced death.

It was then Chris Muldoon’s turn:

AC: I would like you to answer the next two questions either yes, no or I don’t know. Then you can talk for as long as you wish as to why you’ve reached those decisions. But let’s just try to have yes, no, or don’t know.

CM: Ok.

AC: Do you believe that citalopram can cause somebody who would not otherwise take their own life to do so?

CM: Yes.

AC: And is that what you think happened to Yvonne Woodley?

CM: No.

He then went on to outline that there had been debate about the issue that had led to a range of warnings and he cited the National Institute for Healthcare and Clinical Excellence (NICE) guidance, which said:

NICE Guideline

Monitoring risk (page 8):

Monitor for signs of akathisia, suicidal ideas, and increased anxiety and agitation, particularly in the early stages of treatment with an SSRI.

Advise patients of the risk of these symptoms, and that they should seek help promptly if these are at all distressing.

If a patient develops marked and/or prolonged akathisia or agitation while taking an antidepressant, review the use of the drug.

Choice of antidepressant (page 9):

If increased agitation develops early in treatment with an SSRI, provide appropriate information and, if the patient prefers, either change to a different antidepressant or consider a brief period of concomitant treatment with a benzodiazepine followed by a clinical review within 2 weeks.

The doctors to blame?

The effect of this being read out in court was of a company saying we’ve done all we can in terms of warnings. If something went wrong therefore it must have been the doctor’s fault.

Having listened to themselves being put in the frame for blame and in particular having heard the company say their drug can cause suicide, what was the response from the doctors?

Here is the primary care doctor:

AC: And do you believe Citalopram does make people take their own life?

Doc 1: No actually. I think I’m going to say that, because we prescribed her Citalopram in the hope to make her feel better. That was the whole point of her taking it as an antidepressant, to help her to feel better. This is the risk that is reported by BNF and NICE. That is not to say that we’re actually prescribing somebody something that is going to make them kill themselves. I think if we had not prescribed her anything what would be the conclusion then if she’d hung herself? That she hadn’t been treated?

And here the psychiatrist:

AC: Let me ask the same questions I have previously asked the doctors. First do you believe that citalopram can make somebody who would not otherwise take their own life, do so?

Doc 2: I don’t.

AC: You don’t believe it?

Doc 2: No.

AC: So it follows from that that you don’t think that’s what happened to Yvonne?

Doc 2: No.

This exchange makes a number of things clear.

In the Clancy and Woodley cases and in other cases, if asked if their drug has caused this person to commit suicide or homicide, Lundbeck and other companies will always answer No. If asked can your drug cause suicide, they will always contrive to answer the question as though it refers to a particular person and give the impression that there have been no cases where their drug has caused a problem. In a previous post (Psychotic doubt) we have seen Ian Hudson do this.

Companies are legally obliged to say that their drug “can” cause suicide. But doctors are under no such obligation — even under oath.

But if asked up front under oath, they are legally obliged to say that their drug can cause suicide. This is like Philip Morris agreeing smoking can cause lung cancer but denying that it has caused this death or that death from lung cancer.

But an academic, such as an Irish Professor of Psychiatry, or a professional body, like the Irish College of Psychiatrists, are under no such obligation, and they can state even under oath that these drugs do not and cannot cause someone to take their own or another’s life.

The dictionary definition of a model is “a shrunken replica of the real thing”.

So if stuck with a tricky question, other than in court, Lundbeck and other companies can and do defer the questioner to an academic — or to the APA or the Irish College of Psychiatry. They don’t even have to lift the phone. It’s all part of a complete doctoring service.

As the response from Tom Fahy in Professional suicide – the Clancy case shows, this is a new service. One question for those of us who have not retired is whether we want to be represented in this way.

Why call these new doctors “model doctors”? Well, the dictionary definition of a model is “a shrunken replica of the real thing.”

For doctors this is a matter of professional politics.

There are some doctors for whom academics defending drugs like the APA or Irish College have done might be morally distasteful, but for all doctors it is a matter of professional politics. If medications are perfectly safe and very effective, there are much cheaper prescribers, who are much more likely to stick to guidelines than doctors.