Editorial Note: This arrived out of the blue. The list of those copied in makes it look like its anything but spontaneous. Simon Wessely is recently vacated president of Royal College of Psychiatrists, and one of the Trustees of the Science Media Centre. Paul Summergrad and Jeff Lieberman are former presidents of APA. JL offered views on the Holmes case. There is no indication AF has actually watched the program.
From: Allen Frances <email@example.com>
Date: 6 August 2017 at 00:53
Subject: Dear David.
To: David Healy <David.Healy54@googlemail.com>
Cc: Simon Wessely , Barney Carroll , Paul Summergrad , Jeffrey Lieberman , Ronald Pies
I have watched this story play out with deep misgivings. I know you meant well, but also know you went way overboard categorically declaring meds to be the causal factor in this mass murder, when there were so many other possible contributing factors and no real proof meds were among them. It reduces your credibility when you make such extreme statements and also makes it harder for people like me who are trying to curb medication excess, while encouraging its proper use (against the false claims of extremists who somehow blame all psych problems on meds). I know how much flak you have already taken and that you must feel backed into a corner. My recommendation would be that you issue further clarification on the difficulty of establishing causality and the essential benefits, as well as the considerable risks, of psych meds. To do otherwise makes you responsible for patients going off, or refusing to start, meds they may desperately need. Protecting people ffrom unneeded meds is your noble calling, but should not result in your unneceessarily scaring people off needed meds. What do you think?
Allen Frances (@AllenFrancesMD) tweeted at 4:06 PM on Sat, Aug 05, 2017:
I constantly caution re misuse of psych meds
But its extreme to blame mass murder on them
Ignores role of psych disorder/guns/social context https://t.co/gpJ2JpHOzw
On Aug 6, 2017 4:36 AM,
“David Healy” <firstname.lastname@example.org> wrote:
With all due respects you are a long way wide of the mark.
First, aside from a carefully orchestrated campaign, the response from patients and many others has been very positive.
I think the best way into this is to give you two things to read – a piece in the BMJ by Gwen Adshead attached and a response below.
Re: Antidepressants and murder: justice denied
Dr Adshead misses the point behind this program. This was not a program attempting to prove antidepressants can cause homicide. This has already been conceded by prosecutors, regulators and company personnel. As early as 1982, Pfizer personnel had noted that this class of drug (SSRI) were known to cause these reactions.
Nor was it about whether sertraline caused James Holmes to commit murder. Having spent time with the man, my view is that it did, and more could have been done to persuade viewers of this.
The key issue was this. If it has been conceded this drug can cause events like this, and if a case could be made that it did so in this instance, why did Holmes’ legal team not run it?
The answer in part lies in the fact that academic literature on SSRIs is almost entirely ghost-written and there is no access to the data generated by the RCTs of these drugs. The BMJ and other journals play a part in this situation. This means that to acquit Holmes, a lawyer has to persuade a jury that most academics and journals are guilty of failing to adhere to the norms of science.
Holmes was in a Guildford Four quandary. Paraphrasing Lord Denning in that case ” If his [their] story is right, it is such an appalling vista it cannot be. Wrongfully convicted prisoners should stay in jail rather than be freed and risk a loss of public confidence in the law”.
Holmes had a public defender. If he had been wealthy enough to afford a lawyer who relished the challenge, or if the crime was less horrific, things might have been different. The rest of us who end up on the wrong end of one of the close to 100 drugs, including respiratory, skin and cardiac drugs, that prosecutors or companies have indicated can cause violence risk ending up in the same legal quandary Holmes was/is in.
There have been a lot of comments, coordinated by the Science Media Centre, that this program cast aspersions on a useful group of drugs. We need to find some balance between raising alarms about a drug and ensuring we do not compromise an innocent person’s right to a fair trial.
Let me spell out some things in further detail. The Panorama program had vastly more detail on Holmes and his assessment than it could deal with and likely ended up being too subtle for its own good (or maybe for my good). To call this a failure of BBC journalism is as far removed from the truth as you can get. It was one of the best things they have ever done in my opinion.
Second, they do refer to Pfizer judgments their drug can cause psychosis and aggression – which Pfizer opted to put in the label as of 1994 (See the link below). Vanishingly few doctors understand what is going on here. They see a label saying something like “there have been reports of violence and psychosis on our drug so we are including these here” and read this as – look at this wonderfully transparent and responsible company who are putting in the label even whacko reports from nutters and scientologists – am I going to believe this? Don’t be ridiculous.
In fact what is going on is Pfizer and other companies have reports that no matter what way they spin it they cannot explain it in any other way but that our drug has probably caused this.
This is consistent with Pfizer determinations from their healthy volunteer studies in 1982 that sertraline can cause behavioral reactions including agitation/suicidality and aggression/ homicidality and that this class of drug (SSRI) are well recognized to do this. 1982 !
Part of the problem the field has is that the data is inaccessible. If anyone can tell me how anyone can offer expert views in the absence of the data, I’d be interested to hear it. The more we go on with this charade of basing views or guidelines on ghostwritten articles, the less credibility we will all have. Surely Study 329 brought this point home.
The second point is this. Before this program came out, the Science Media Centre had lined up statements from high ranking figures including Wendy Burn President of the Royal College of Psychiatrists to slam the program – in terms that had nothing to do with what was in the program – her statement talks about stigmatizing mental illness. WB later confessed she hadn’t seen the program when she made the statement. She has no expertise in this area. It’s not clear to me she authored her view. SMC have continued to coordinate inputs that have little to do with the real issues at the heart of the program.
Who are SMC? They are linked to Sense about Science. Simon can probably tell you more. My take is the original idea was reasonable – scientists like him were under attack from what might loosely called activists. He probably had much less hostility to cope with than I have had defending ECT. But the idea was to ensure that proper science got a hearing.
The reality today is that funded by public money and almost any major corporation you can think of whose interests intersect with healthcare, SMC get preprints of all articles from BMJ for instance – such as my piece some years ago – So Long and thanks for all the Serotonin – and approach the Royal College to get experts who can diss the piece when it appears. (I wouldn’t make a statement like this without the documents to back it up).
This is stifling proper science. It has become nasty and risks being fascist. It’s dangerous for both patients and medics. As I’ve tried to tell SW on several occasions unless medicine embraces the idea that the magic of medicine and doctors is that we bring good out of the use of a poison, we are fucked.
If the drugs are wonderfully effective, and free from problems other than notional ones, then we are costly prescribers and it is no accident we are at present being phased out. This may not be a problem for you Allen but it is for my children and everyone else in that generation.
If the drugs do what the guidelines would suggest, then managers can tell shrinks what to do and we are losing our jobs if we don’t comply. This is not a world in which you had to practice Allen but I can tell you its not pleasant.
As a hard core supporter of the medical model and someone who doesn’t advocate for anything other than physical treatments, I look at the current state of psychiatry and a lot of medicine with increasing dismay and would make sure anyone thinking of taking up psychiatry knows it is an increasingly grim profession where the excitement if any lies in working out how we have messed up so badly and how to turn things round.
Re reducing the burden of over-medication – well 10% of the UK and most other major countries are on antidepressants. There is no increase in the numbers being put on them year on year. The yearly increase comes from those toppling over into chronic use at the end of their first year of use. When I began practicing we figured antidepressants should be used for 3 months – perhaps 6 months occasionally. Of the 10% of people in the UK on these drugs, 90% roughly are on them for more than a year primarily because they can’t get off – there are several reasons why this might be.
Here is a link to the P program.
It’s worth watching. But remember it’s subtle. They left out lots – including the healthy volunteer material and the clips of Bill Reid saying he knew nothing about the drugs and there was no point asking him about drugs – you’d better get someone else to comment on that.
After watching, the issues I’d be interested in hearing views on are the following:
- Having offered comparatively few views in cases involving SSRIs, mostly views that the drug has played no part in whatever event, I believe there are a number of innocent people wrongly convicted and many people who will never get a fair trial. What can we do about this?
- Recognizing that prosecutors in the case of Zoloft, companies in the case of all these drugs, and the data where it is available, make it close to incontestable that SSRIs in principle can cause violence, and recognizing that patients are far more sensible than we usually give them credit for and can manage a genuine debate, how do we conduct a debate about these issues?
- It seems to me we are failing the F Scott Fitzgerald test: “The test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function”. Why might this be?
- Are organizations like SMC a good thing or not and if a good thing do they need a new brief – looking after the interests of a profession rather than the interests of corporations and their products?
From: Allen Frances <email@example.com>
Date: 6 August 2017 at 14:20
You make my point much more eloquently & succinctly than I ever could with this quotation at the end of your response:
It seems to me we are failing the F Scott Fitzgerald test: “The test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function”. Why might this be?
I think you need to address your own question to yourself- why might it be that you (who obviously otherwise have the highest intelligence), are so willing to go propagate the one sided extremes emphasizing the potential for bad complications from meds without being able to hold as well the opposed idea that for many the meds are desperately needed and of very favorable risk/benefit. In my view, your being unable to hold these 2 opposing ideas greatly reduces your effectiveness as reformer of psychiatry and risks disaster for patients who do need meds.
I also don’t understand how you can be so sure of yourself and make such definitive statements about an inherently multicausal act. How can you or anyone prove it was just meds that caused murder. You must know that nothing in psychiatry and human behavior is that simple, but you seem not to know the possible harms that follow when you make it seem so.
I fear that the great good you have done and will do in pointing out the risks/harms of meds is tarnished by your radically extreme position and inability to also appreciate benefits. I know we have been over this many times before and don’t want to make what must be a difficult time more difficult. My goal is not to change your mind, but to open it a little and to suggest that you are now embattled not just because there are some corrupt forces aligned against you, but also because you have gone overboard in taking an indefensible one sided position.
Thanks for the dialog. Even if it goes nowhere I felt compelled to once again raise our differences. Hope the dust settles.
David Healy <firstname.lastname@example.org>
Date: 6 August 2017 at 14:44
You are either not reading what I’ve written or not thinking about it.
I would hardly say I believe in the medical model probably even more than you and advocate nothing but physical treatments if they didn’t do some good.
I think you are making the mistake of thinking good comes out of the use of a pill – when in fact it comes from doctors use of pills – or not. And if we don’t keep doctors and patients fully informed of all the effects of pills they are much less likely to be able to bring benefits out of them.
Can you tell me where you get the idea I am embattled from? I expect an SMC campaign – this is just the rough and tumble that someone who is concerned about patients and the profession has to put up with these days. Aside from this I am not aware of much else – certainly nothing of substance that engages the issues.
Its not me being so sure of myself. Companies have been sure in the case of close to 1000 different meds that they have caused psychosis and over several hundred that they have caused violence.
This has been the case for Zoloft for over two decades. Do you think you’re looking after the interests of patients saying nothing about this?
From: Allen Frances <email@example.com>
Date: 6 August 2017 at 18:45
It is not deceiving the public to take a balanced position that meds can benefit and meds can harm.
It is deceiving the public to assert with certainty that you know meds caused this mass murder.
And the vulnerable populations I worry about (& you should too) are not the many worried well who are over medicated, but the few very ill who desperately need meds & will be scared off them by your overly dramatic and unsupportable claims to omniscience that Holmes acted only their influence. Every act can have unintended harmful consequences. You are nobly trying to help people, but the extremity of your views and unwarranted certainty hurts others.
From: David Healy <firstname.lastname@example.org>
Date: 6 August 2017 at 20:20
I was puzzled “extremity of my views” – about the medical model or access to data – until I realized you were talking about my old style twentieth century making a diagnosis as opposed to taking a brain scan.
Having interviewed the man at some length and seen 24 hours of others interview him on tape and having read many other reports – all from people who quite happily say they know nothing about the effects of the drugs, and having had access to vast amounts of other material – computer records, texts etc – and having gone into it not thinking the drug played a part – I only went because the lawyers insisted – yes I am very happy this would not have happened but for the drug in this case. Holmes has no sense that I thought that.
I remain the only person with any expertise in the drugs in this case who has interviewed him etc – so I don’t really know what basis you have for thinking my views extreme.
I have no idea what it would take to get you to realise this is not about Holmes innocence or guilt – he is gone away forever and would have preferred to be dead. The issue is that very few people in the US or UK in anything remotely resembling this situation are getting a fair trial.
Long before Holmes I approached ACLU about this issue – who wanted nothing to do with it for fear of jeopardising prisoners access to healthcare. I realize there is an access to healthcare issue in the US but I don;t think the people on this list need to act like you are an embattled minority. Your job is to change this so both those not getting care and those not getting justice get a better deal