- Email: [email protected]
Antipsychiatry and the antidepressants debate
Correspondence
The civil and political rights of people with mental illness1 continue to be violated across the world. What little resources are allocated to addressing mental illness are strictly focused on medical treatment of patients, not their right to live with dignity as equal members of society. Herein lies the greatest paradox in psychiatry and global mental health. Global initiatives like the Movement for Global Mental Health and the Grand Challenges in Global Mental Health 2 advocate that effective psychiatric treatment exists3 and what we need is to scale-up these services4 to include the entire population who meet the criteria for treatment. However, in the absence of support from the beneficiary communities (ie, patients), real change in mental health—in which services are not only available but also sought—is unlikely. A cursory examination of the history of successful rights movements (for people with HIV, women, people with disabilities, and LGBT) shows the central role of the communities involved. In psychiatry, however, people with mental illness still have almost no stake. A prejudice, seemingly a result of the historical baggage of psychiatry, looms over mental health, including the global mental health movement, with professionals often continuing to view people with mental ill health simply as passive recipients of treatment. The Movement for Global Mental Health and the Grand Challenges in Global Mental Health do, however, hold tremendous potential to transform the scope and understanding of mental health globally. They would do well to learn from other rights movements. They must part ways with traditional psychiatry by vocally advocating the rights of people with mental ill health, ensuring that they are treated equally www.thelancet.com/psychiatry Vol 1 August 2014
before the law and in society. Human rights are indispensable in mental health and must include the civil and political rights of those with mental ill health. The adoption of the United Nations’ Convention on the Rights of Persons with Disabilities5 in 2006 created an unprecedented opportunity to strengthen global advocacy for the social, political, and legal legitimacy of users of mental health services. If the global mental health movement fails to capitalise on this historic opportunity to make space for patients in their initiatives, mental health services will remain stigmatised and unwanted. I declare no competing interests.
Jagannath Lamichhane [email protected] Public Health Foundation of India, Vasant Kunj, New Delhi, DL 110070, India 1
2
3
4
5
Drew N, Funk M, Tang S, et al. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. Lancet 2011; 378: 1664–75. Collins P, Patel V, Joestl S, March D. Grand challenges in global mental health. Nature 2011; 475: 7–10. Patel V, Araya R, Chatterjee S, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370: 991–1005. Eaton J, McCay L, Semrau M, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378: 1592–603. UN. Convention on the Rights of Persons with Disabilities and Optional Protocol. United Nations: New York; 2006.
Antipsychiatry and the antidepressants debate We read with interest the comment by David Nutt and colleagues. 1 Although their comments have many merits and some interesting analogies, we think that the subject is too important to reduce it to a mere opposition of pro-psychiatry and antipsychiatry. Of course antidepressants can be useful in many situations. They have been studied in randomised controlled trials and have shown their efficacy compared with placebo
for major depressive disorder. In the context of evidence-based medicine, one might consider that the debate should stop there. Nevertheless, it is now agreed that the effects of antidepressants are overestimated because of a major publication bias 2 and they show clinically significant differences only for severe cases of depression.3 In addition, in a real-life setting, depressed patients are not the typical patients enrolled in randomised controlled trials: while their depressive disorders are often less severe, depressed patients have more numerous somatic and psychiatric comorbidities. Conversely, many patients who do not meet the criteria for major depressive disorder are treated with antidepressants for depression. This implies major difficulties for translating antidepressant efficacy (in optimal circumstances) into effectiveness (in a real-life setting).4 As for empirically based psychotherapies, they are presented as equipotent to pharmacotherapies for non-delusional outpatients with major depressive disorder in the 2007 International College of NeuroPsychopharmacology (CINP) Task Force report on the treatment of depression,5 and the CINP can hardly be considered as an anti-psychiatry movement. If we acknowledge that the level of evidence for psychotherapies is likely to be weaker than that for medication, is this a result of a difference in effectiveness, or of the spectacular difference in the amount of money spent on evaluating these treatments? Finally, concerning the dualistic impasse raised by Nutt and colleagues, we do agree that treatments for the brain can be used to deal with problems of the mind. But psychiatric patients are also thinking individuals who suffer, and most of them are looking for professionals that can talk to them, who consider them as a thinking person and not solely as a dysfunctional brain.
Antonio Melita/Demotix/Corbis
Strengthening civil and political rights of people with mental illness
173
Correspondence
These remarks on antidepressants are in fact remarks about evidencebased medicine and could be transposed to many other medical conditions. We are not sure that Peter Gøtzsche has anything in common with the anti-psychiatry current. Despite the fact that it was polemic, when he was critical of screening for breast cancer using mammography, 6 nobody claimed that it was a tragic manifestation of the anti-gynaecology current. FN is a board member for Bristol-Myers Squibb and has received expenses for travel or accommodation from Servier, Lundbeck, and Janssen. BF has been a consultant for Sanofi-Aventis, Servier, Pierre-Fabre, Merck Sharp & Dohme, Lilly, Janssen-Cilag, Otsuka, Lundbeck, Genzime, Novartis, Roche, GlaxoSmithKline, and Bristol-Myers Squibb. We thank Angela Swaine Verdier for revising the English.
*Florian Naudet, Bruno Falissard fl[email protected] INSERM U669, Université Paris-Sud and Université Paris Descartes, UMR-S0669, Paris Cedex 14, France 1
2
3
4
5
6
Nutt DJ, Goodwin, GM, Bhugra D, Fazel S, Lawrie S. Attacks on antidepressants: signs of deep-seated stigma? Lancet Psychiatry 2014; 1: 102–104. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358: 252–60. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45. Naudet F, Millet B, Reymann JM, Falissard B. Improving study design for antidepressant effectiveness assessment. Int J Methods Psychiatr Res 2013; published online Aug 30. DOI:10.1002/mpr.1391. Sartorius N, Baghai TC, Baldwin DS, et al. Antidepressant medications and other treatments of depressive disorders: a CINP Task Force report based on a review of evidence. Int J Neuropsychopharmacol 2007; 10 (suppl 1): S1–207. Gotzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000; 355: 129–34.
David Nutt and colleagues1 represent a brand of psychiatry that wishes to keep its eyes firmly shut when evidence of harms and lack of effectiveness of favoured biological treatments are found. It is therefore unsurprising they take issue with the Council for Evidence-based Psychiatry 174
for publicising evidence that rarely gets discussed; evidence that would enable people to make properly informed decisions about whether they will benefit from drug treatments that research shows can cause serious, persistent adverse effects. We believe in the importance of psychiatry, but also in the dictum of “first do no harm”, and in the role that critical thought has in genuine scientific progress. We are therefore tired of the intellectual malaise, corruption, and indifference some sections of academic psychiatry seem to have developed. We are also deeply concerned about the potentially devastating impact this blindness is having on the lives of millions of people who have been on the receiving end of a pharmaceutical revolution borne out of good marketing manipulating poor science. The record of this brand of psychiatry is poor. As David Kingdon and Allan Young 2 have put it: “Research into biological mechanisms of mental and behavioural responses has failed to deliver anything of value to clinical psychiatrists and is very unlikely to do so in the future.” Similarly, Arthur Kleinman3 has predicted the current biology-based model of academic psychiatry will be ruinous to the profession due to its consistent failure to deliver. Peter Gøtzsche, director of the Nordic Cochrane Centre, has dealt with the counter-evidence on the specific issue of antidepressant prescribing.4 He shows how Nutt and colleagues have succumbed to the tendency to minimise harms and exaggerate benefits in a way that puts patients at risk and leaves them without access to balanced information. And in terms of stigma, the evidence consistently finds that it is the idea that mental illness is like any other illness that is most likely to lead to stigma5 and so to more potential pain and suffering for patients. Throughout its history, psychiatry has been slow to admit the negative effects of its drugs, as is well documented in
the case of antipsychotic drugs and tardive dyskinesia. By branding severe adverse reactions to antidepressants as unexplained medical symptoms distorted by the incentive of litigation, Nutt and colleagues’ perpetuate this tendency and pour scorn on the experience of patients and their families. The Council for Evidencebased Psychiatry finds this insulting and shameful. British withdrawal-support charities report alarming numbers of people suffering disabling symptoms for multiple years following withdrawal from antidepressants. We surely need this issue properly researched rather than summarily—and offensively— dismissed. The future of more humane care and a properly scientific profession depends on our willingness to engage with such uncomfortable realities. All authors are members of the Council for Evidence-based Psychiatry. We declare no competing interests.
Sami Timimi, Philip Thomas, *James Davies, Peter Kinderman University of Lincoln, Lincoln, UK (ST), University of Roehampton, London, UK (JD), University of Liverpool, Liverpool, UK (PK). PT has no affiliation. 1
2
3
4
5
Nutt DJ, Goodwin GM, Bhugra D, Fazel S, Lawrie S. Attacks on antidepressants: signs of deep-seated stigma? Lancet Psychiatry 2014; 1: 102–04. Kingdon D, Young A. Research into putative biological mechanisms of mental disorders has been of no value to clinical psychiatry. Br J Psychiatry 2007; 191: 285–90. Kleinman A. Rebalancing academic psychiatry: why it needs to happen – and soon. Br J Psychiatry 2012; 201: 421–22. Gøtzsche PC. Why I think antidepressants cause more harm than good. Lancet Psych 2014; 1: 104–06. Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. Br J Psychiatry 2011; 199: 367–72.
Effects of patient suicide on the multidisciplinary care team We were interested to read the findings of Alexandra Pitman and colleagues1 with regards to the effects of suicide on the mental health of relatives. We www.thelancet.com/psychiatry Vol 1 August 2014
The civil and political rights of people with mental illness1 continue to be violated across the world. What little resources are allocated to addressing mental illness are strictly focused on medical treatment of patients, not their right to live with dignity as equal members of society. Herein lies the greatest paradox in psychiatry and global mental health. Global initiatives like the Movement for Global Mental Health and the Grand Challenges in Global Mental Health 2 advocate that effective psychiatric treatment exists3 and what we need is to scale-up these services4 to include the entire population who meet the criteria for treatment. However, in the absence of support from the beneficiary communities (ie, patients), real change in mental health—in which services are not only available but also sought—is unlikely. A cursory examination of the history of successful rights movements (for people with HIV, women, people with disabilities, and LGBT) shows the central role of the communities involved. In psychiatry, however, people with mental illness still have almost no stake. A prejudice, seemingly a result of the historical baggage of psychiatry, looms over mental health, including the global mental health movement, with professionals often continuing to view people with mental ill health simply as passive recipients of treatment. The Movement for Global Mental Health and the Grand Challenges in Global Mental Health do, however, hold tremendous potential to transform the scope and understanding of mental health globally. They would do well to learn from other rights movements. They must part ways with traditional psychiatry by vocally advocating the rights of people with mental ill health, ensuring that they are treated equally www.thelancet.com/psychiatry Vol 1 August 2014
before the law and in society. Human rights are indispensable in mental health and must include the civil and political rights of those with mental ill health. The adoption of the United Nations’ Convention on the Rights of Persons with Disabilities5 in 2006 created an unprecedented opportunity to strengthen global advocacy for the social, political, and legal legitimacy of users of mental health services. If the global mental health movement fails to capitalise on this historic opportunity to make space for patients in their initiatives, mental health services will remain stigmatised and unwanted. I declare no competing interests.
Jagannath Lamichhane [email protected] Public Health Foundation of India, Vasant Kunj, New Delhi, DL 110070, India 1
2
3
4
5
Drew N, Funk M, Tang S, et al. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. Lancet 2011; 378: 1664–75. Collins P, Patel V, Joestl S, March D. Grand challenges in global mental health. Nature 2011; 475: 7–10. Patel V, Araya R, Chatterjee S, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370: 991–1005. Eaton J, McCay L, Semrau M, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378: 1592–603. UN. Convention on the Rights of Persons with Disabilities and Optional Protocol. United Nations: New York; 2006.
Antipsychiatry and the antidepressants debate We read with interest the comment by David Nutt and colleagues. 1 Although their comments have many merits and some interesting analogies, we think that the subject is too important to reduce it to a mere opposition of pro-psychiatry and antipsychiatry. Of course antidepressants can be useful in many situations. They have been studied in randomised controlled trials and have shown their efficacy compared with placebo
for major depressive disorder. In the context of evidence-based medicine, one might consider that the debate should stop there. Nevertheless, it is now agreed that the effects of antidepressants are overestimated because of a major publication bias 2 and they show clinically significant differences only for severe cases of depression.3 In addition, in a real-life setting, depressed patients are not the typical patients enrolled in randomised controlled trials: while their depressive disorders are often less severe, depressed patients have more numerous somatic and psychiatric comorbidities. Conversely, many patients who do not meet the criteria for major depressive disorder are treated with antidepressants for depression. This implies major difficulties for translating antidepressant efficacy (in optimal circumstances) into effectiveness (in a real-life setting).4 As for empirically based psychotherapies, they are presented as equipotent to pharmacotherapies for non-delusional outpatients with major depressive disorder in the 2007 International College of NeuroPsychopharmacology (CINP) Task Force report on the treatment of depression,5 and the CINP can hardly be considered as an anti-psychiatry movement. If we acknowledge that the level of evidence for psychotherapies is likely to be weaker than that for medication, is this a result of a difference in effectiveness, or of the spectacular difference in the amount of money spent on evaluating these treatments? Finally, concerning the dualistic impasse raised by Nutt and colleagues, we do agree that treatments for the brain can be used to deal with problems of the mind. But psychiatric patients are also thinking individuals who suffer, and most of them are looking for professionals that can talk to them, who consider them as a thinking person and not solely as a dysfunctional brain.
Antonio Melita/Demotix/Corbis
Strengthening civil and political rights of people with mental illness
173
Correspondence
These remarks on antidepressants are in fact remarks about evidencebased medicine and could be transposed to many other medical conditions. We are not sure that Peter Gøtzsche has anything in common with the anti-psychiatry current. Despite the fact that it was polemic, when he was critical of screening for breast cancer using mammography, 6 nobody claimed that it was a tragic manifestation of the anti-gynaecology current. FN is a board member for Bristol-Myers Squibb and has received expenses for travel or accommodation from Servier, Lundbeck, and Janssen. BF has been a consultant for Sanofi-Aventis, Servier, Pierre-Fabre, Merck Sharp & Dohme, Lilly, Janssen-Cilag, Otsuka, Lundbeck, Genzime, Novartis, Roche, GlaxoSmithKline, and Bristol-Myers Squibb. We thank Angela Swaine Verdier for revising the English.
*Florian Naudet, Bruno Falissard fl[email protected] INSERM U669, Université Paris-Sud and Université Paris Descartes, UMR-S0669, Paris Cedex 14, France 1
2
3
4
5
6
Nutt DJ, Goodwin, GM, Bhugra D, Fazel S, Lawrie S. Attacks on antidepressants: signs of deep-seated stigma? Lancet Psychiatry 2014; 1: 102–104. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358: 252–60. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45. Naudet F, Millet B, Reymann JM, Falissard B. Improving study design for antidepressant effectiveness assessment. Int J Methods Psychiatr Res 2013; published online Aug 30. DOI:10.1002/mpr.1391. Sartorius N, Baghai TC, Baldwin DS, et al. Antidepressant medications and other treatments of depressive disorders: a CINP Task Force report based on a review of evidence. Int J Neuropsychopharmacol 2007; 10 (suppl 1): S1–207. Gotzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000; 355: 129–34.
David Nutt and colleagues1 represent a brand of psychiatry that wishes to keep its eyes firmly shut when evidence of harms and lack of effectiveness of favoured biological treatments are found. It is therefore unsurprising they take issue with the Council for Evidence-based Psychiatry 174
for publicising evidence that rarely gets discussed; evidence that would enable people to make properly informed decisions about whether they will benefit from drug treatments that research shows can cause serious, persistent adverse effects. We believe in the importance of psychiatry, but also in the dictum of “first do no harm”, and in the role that critical thought has in genuine scientific progress. We are therefore tired of the intellectual malaise, corruption, and indifference some sections of academic psychiatry seem to have developed. We are also deeply concerned about the potentially devastating impact this blindness is having on the lives of millions of people who have been on the receiving end of a pharmaceutical revolution borne out of good marketing manipulating poor science. The record of this brand of psychiatry is poor. As David Kingdon and Allan Young 2 have put it: “Research into biological mechanisms of mental and behavioural responses has failed to deliver anything of value to clinical psychiatrists and is very unlikely to do so in the future.” Similarly, Arthur Kleinman3 has predicted the current biology-based model of academic psychiatry will be ruinous to the profession due to its consistent failure to deliver. Peter Gøtzsche, director of the Nordic Cochrane Centre, has dealt with the counter-evidence on the specific issue of antidepressant prescribing.4 He shows how Nutt and colleagues have succumbed to the tendency to minimise harms and exaggerate benefits in a way that puts patients at risk and leaves them without access to balanced information. And in terms of stigma, the evidence consistently finds that it is the idea that mental illness is like any other illness that is most likely to lead to stigma5 and so to more potential pain and suffering for patients. Throughout its history, psychiatry has been slow to admit the negative effects of its drugs, as is well documented in
the case of antipsychotic drugs and tardive dyskinesia. By branding severe adverse reactions to antidepressants as unexplained medical symptoms distorted by the incentive of litigation, Nutt and colleagues’ perpetuate this tendency and pour scorn on the experience of patients and their families. The Council for Evidencebased Psychiatry finds this insulting and shameful. British withdrawal-support charities report alarming numbers of people suffering disabling symptoms for multiple years following withdrawal from antidepressants. We surely need this issue properly researched rather than summarily—and offensively— dismissed. The future of more humane care and a properly scientific profession depends on our willingness to engage with such uncomfortable realities. All authors are members of the Council for Evidence-based Psychiatry. We declare no competing interests.
Sami Timimi, Philip Thomas, *James Davies, Peter Kinderman University of Lincoln, Lincoln, UK (ST), University of Roehampton, London, UK (JD), University of Liverpool, Liverpool, UK (PK). PT has no affiliation. 1
2
3
4
5
Nutt DJ, Goodwin GM, Bhugra D, Fazel S, Lawrie S. Attacks on antidepressants: signs of deep-seated stigma? Lancet Psychiatry 2014; 1: 102–04. Kingdon D, Young A. Research into putative biological mechanisms of mental disorders has been of no value to clinical psychiatry. Br J Psychiatry 2007; 191: 285–90. Kleinman A. Rebalancing academic psychiatry: why it needs to happen – and soon. Br J Psychiatry 2012; 201: 421–22. Gøtzsche PC. Why I think antidepressants cause more harm than good. Lancet Psych 2014; 1: 104–06. Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. Br J Psychiatry 2011; 199: 367–72.
Effects of patient suicide on the multidisciplinary care team We were interested to read the findings of Alexandra Pitman and colleagues1 with regards to the effects of suicide on the mental health of relatives. We www.thelancet.com/psychiatry Vol 1 August 2014