Deprescribing

For a change.

In March this year, there was a fairly important event in psychiatry, the publication of The Maudsley Deprescribing Guidelines, by Mark Horowitz and David Taylor. Mark Horowitz is Australian and recently did a lecture tour, so there’s considerable interest in the book although, as we will see, not all favourable. At 600 pages, the Guideline still working its way up my intend-to-read list. The Maudsley Hospital and its associated Institute of Psychiatry in London are more or less the centre of gravity of British psychiatry, very strong on the biology and genetics of mental disorder, and have had a huge influence on Australian psychiatry. For decades, anybody who wanted to get ahead in academic psychiatry in this country did a pilgrimage to “The Maudsley” to learn at the feet of the greats, so whatever happened there became gospel here. Whether that’s still true, I don’t know but my impression is Australian academic psychiatrists have let go of one of Mummy England’s hands and latched on to a spare American hand (meaning their feet don’t quite touch the ground).

In December last year, a brief (600 word) letter [1] appeared in the British Medical Journal, signed by 31 authors influential in the world of Critical Psychiatry, to set the scene for the book: “We… call for the UK government to commit to a reversal in the rate of prescribing of antidepressants … we hope other countries with high levels of antidepressant prescribing will also commit to a reversal in prescribing rates” (that’s a pointed reference to Australia). You can’t do much in 600 words (the book is 600 pages) but they argued that high levels of antidepressant prescription have not led to an improvement in mental health, or have even made things worse. Most people have been prescribed the drugs for minor depressive states, for which they are probably ineffective. However, antidepressants aren’t sweets, they have a long list of serious side effects and patients soon become dependent on them. Many people end up taking them in the long to very long (20-30years) term. This is not just costing the UK NHS a fortune, but huge numbers of patients would be better off with some other (non-drug) management, or even no treatment at all.

Nine months later, Australia’s doughty defenders of the orthodoxy cranked themselves into action. In a very long editorial (3340 words) in the journal Australasian Psychiatry, no less than seven members of the journal’s editorial board (all academics) threw themselves at the hole the Guidelines have punched in their wall of denial. Since “All authors contributed to the conceptualisation, research and policy analysis, and writing of this Editorial,” we can presume they spent quite a lot of government time on it. The immediate question is: "Why?" Why would they bother? The letter and the book don’t say anything that any half-sensible member of the community would object to: the drugs are not very effective, they’re expensive and have a lot of side effects, we can do better with other means so we need to reduce them and change our policies. Who would object to that? Well, a lot of academics who have made their careers out of pushing psychiatric drugs get very nervous with that sort of sedition. I mean, patients might hear of it or, perish the thought, medical students. Oh dear.

What does the editorial say? Before we start on it, readers might like to have another look at the posting on William Lutz’s idea of Doublespeak (August 6^th). Lutz saw four varieties: Euphemism, where something unpleasant or shocking is rephrased in acceptable language; jargon, where the speaker uses technical terms that sound impressive but confuse the audience; gobbledygook, which is just loud but hollow talk, and inflated language, which makes the ordinary sound impressive. This editorial has lots of examples of Doublespeak.

It starts with a pleasant statement: “We agree that not all antidepressant prescribing is warranted.” OK, that seems to be the end of the matter because that’s all the letter says. But we’re dealing with academics here, who, if they can’t find something to dispute, are out of a job. Quoting clinical guidelines for antidepressants for Australian and New Zealand, and the UK, they say that in mild to moderate depression, “… antidepressants are not necessarily recommended as first line treatments …” (correct). They point out that GPs are by far the main source of antidepressants (true), and “… as awareness and recognition of depression has increased there has been a higher prevalence of use …” (very dubious). Antidepressants have a lot of side effects (agreed), but then they quote a large study from general practice in the UK, the ANTLER study (2021) [2], that seems to argue that people are better off with long-term drugs.

In this study, nearly 500 people taking antidepressants were divided in two groups. One group continued with their drugs as normal while the other stopped them. All patients were reassessed five times over the next year. 56% of those who stopped their drugs relapsed, compared with only 39% of those who continued. Those who stopped reported a lot of withdrawal symptoms, peaking at 12 weeks after stopping. However, I think their project design was faulty: they stopped the antidepressants far too quickly (one month for fluoxetine, 2 months for the rest) and hardly tapered at all. All the patients would have known whether they were getting their usual active drugs or not. Moreover, I can’t find anything to suggest that the drug-free patients were getting any treatment at all, so the project compared treated patients with patients who were not just untreated but who were set up for drug withdrawal symptoms. They concluded that the treated did a little less badly. This is hardly rocket science.

So far, the editorial has agreed with everything the letter said: too many people are taking too many antidepressants for too long for too few reasons, thereby paying too much to get too many side effects for barely any benefit. So why are they arguing? We press on. On p3, the editors raise the question of “depressed patients in whom the risk of relapse is high…” These patients, they say, should continue their drugs. That’s fine, but how do we assess whether they are at “high risk”? There must be factors in the patient’s life that are blinking red, that add up to “continue the drugs.”

However, if there are factors in the patient’s life that indicate a poor outlook, surely the correct move is to deal with the factors? Mrs Smith has to put up with a drunken abusive husband. Shouldn’t we deal with that rather than just leave her on the drugs to sit stunned at home, getting fatter every month? Maybe some of the money spent on drugs should be spent on more public housing for women with children in abusive relationships. In my old-fashioned view, the job of the psychiatrist is to identify those factors and provide solutions. If, after that, the patient is still too depressed to function, then antidepressants may be indicated, but not until then. But here’s the problem: the seven editors who wrote this editorial all believe depression is a biological disease of the brain. They don’t believe that non-biological factors can cause a severe mental disorder. They are caught in the grip of an ideology of mental disorder [3] that tells them what to see, what to listen to, what to do, yet they have no scientific model of mental disorder.

We see this further down p3: “We agree … that antidepressants are being prescribed at higher rates … Further, their usage in health economics studies reveals patient preferences, which are for the prescription of antidepressants” (their emphasis, although I’m not sure why). Hang on, what did they say? The rising prescription rates for antidepressants are due to patients asking for them? What utter rubbish. Patients don’t decide “I need some antidepressants, I’ll see my GP for a script.” They say: “I’m feeling crap, better see somebody.” That means seeing their GPs, and what happens after that is decided by the GP, not by the patient. These days, after decades of indoctrination by drug companies and academic shills, drugs have become the first line of management, not the third or fourth, which is precisely what the Guidelines are about. Moreover, when patients are given an honest list of the likely side effects of these drugs, the majority will decline them. They take them only on the recommendation of the medical profession, whom they trust, and their trust is abused.

Moving on, we have a superb example of gobbledygook:

Another complication is that the population experiencing depression is not homogeneous – indeed, it is extremely varied and subject to additional variances due to geographical differences in resources, as well as varying levels of understanding and perspectives regarding how depression should be diagnosed and treated (p3).  

That says: Depression is NOT a single “disease,” everybody’s different, diagnostic standards are different, treatment is different. To me, that looks like they have just lost their case but down the page, they have another go at blaming patients for excessive drug prescription: “Patient revealed preferences for antidepressant treatment inherent in the rising prescribing rate …” That’s simply not true but, on the off-chance there may be a grain of truth in it, then surely all the millions of advertisements in public toilets and everywhere saying “Feeling depressed? See your doctor” are responsible? It is used to be that nobody wanted the label "mental” but these days, people compete for the most exotic diagnoses. And with a diagnosis come … you got it, drugs. But now we get to the weird stuff.

On p4 of their editorial, the G7 announce:

 … it remains unclear who these medications are being administered to and indeed why. Therefore, it is not possible to determine the appropriateness of the prescribing patterns.

Hang on, have we read this correctly? Is it true that they, the assembled and largely self-appointed “experts” on mental disorder, are defending Australia’s very high rate of prescription of antidepressants by saying “We don’t know who’s getting them or why or whether they should be”? Shouldn’t that be settled before the first script is issued? Apparently not. Instead, they’ve waited fifty years and billions of dollars, not to mention all those wrecked lives and the suicides on tricyclics, to start asking the most elementary questions about the drugs. In fact, there are several questions they should ask before those:

1.      Is depression a real thing?

2.      Is it the sort of thing that will respond to drugs?

3.      Is it the sort of thing that ought to be treated with drugs?

Mainstream psychiatry has never answered these questions. As an ideology of mental disorder [3], biological-type psychiatrists assume, but have never proven, that depression is necessarily and only going to respond to drugs. But after a series of secret meetings, and after admitting they don’t know what they’re doing with antidepressants or why, our intrepid editors have decreed that anybody who disagrees with them, such as the misguided souls who wrote The Maudsley Deprescribing Guidelines, is “likely to do more harm than good” (p5). This is after they have agreed with practically everything in the book. Truly amazing. But that’s what you can do with Doublespeak, you can convince your audience that black is white.

There’s a lot more to this editorial but dealing with each artfully misleading point would take hours. It stands as a stands as a clear example of how the worst delusion in psychiatry is self-delusion: before you can fool your audience, you have to fool yourself.

Reference:

1.      Davies J et al (2023). Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. BMJ 2023; 383: 2730. doi: https://doi.org/10.1136/bmj.p2730 (Published 05 December 2023)

2.      Duffy L, Clarke CS, Lewis G, Marston L, Freemantle N, Gilbody S, et al. Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT. Health Technol Assess 2021;25(69)     https://doi.org/10.3310/hta25690

3.      McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.

The cost of these drugs is high. At about AU$20 per dispensed script per month, 3 million adults taking them for a year costs in the order of AU$720million. That’s why drug companies put so much effort into convincing academic psychiatrists that biology is the only way to go.

Error: My post on Sept. 3^rd on Peter Gøtzsche’s new book should have read:

Prof. Gøtzsche was co-founder of the Cochrane Collaboration and, for 25 years, director of the Nordic Cochrane Centre in Copenhagen, until the Cochrane Collaboration’s new CEO, journalist Mark Wilson, decided to take it in a different direction and pushed him out.