101 Uses for a Dead Journal

There used to be a wonderful cartoon series called 101 Uses for a Dead Cat, which led me 25 years ago to give a talk at a British Association for Psychopharmacology meeting entitled 101 Uses for a Dead Psychiatrist. That was back in the days when Psychopharmacology meetings were places of debate and the British Journal of Psychiatry was guaranteed to have something of real interest in every issue. Under a series of editors the Journal was so good that it still inspires affection in the likes of me and an older generation of psychiatrists – worldwide.

Perhaps as a legacy of those times, the BJP now runs an interesting little corner in which they invite authors to distill the essence of an issue into 100 words.

This isn’t as easy as it might sound. It’s like composing a haiku or limerick or tweet – if you’re not used to it, it takes time to get the balance right especially when they invite you to write 100 words on Psychiatry and the Pharmaceutical Industry, as they asked me 3 years ago.

After a lot of revisions, this is what I ended up with:

“Little Pharma made profits by making novel compounds; Big Pharma does it by marketing. Doctors say they consume (prescribe) medication according to the evidence, so marketeers design and run trials to increase a drug’s use. They select the trials, data and authors that suit, publish in quality journals, facilitate incorporation in guidelines, then exhort doctors to practice evidence-based medicine. Because “they’re worth it”, doctors consume branded high cost but less effective “evidence-based” derivatives of older compounds making these drugs worth more than their weight in gold. Posted parcels meanwhile are tracked far more accurately than adverse treatment effects on patients.”

As it turns out, here was a manifesto for RxISK before RxISK was a glint in anyone’s eye. The journal accepted it without demur.

But the climate had been slowly changing with the chill spreading from the heart out to the extremities as happens in the most serious conditions. The journal has been getting a lot less interesting. There are few people I know who confess to reading any of its seemingly evidence based pieces.

I had already had a problem when asked to do a book review – 300 words. Again difficult to distill the essence of an important and complex book like The Loss of Sadness into 300 words. I was pleased with the outcome but the journal wasn’t and approached someone else to provide a review. I thought about protesting but let it pass – this will be a future post.

I was then asked to review one of these in all probability ghostwritten evidence based pieces, an article comparing escitalopram and venlafaxine. This article had a heavy sprinkling of the flaws found in pharmaceutical company trials outlined in Ben Goldacre’s Bad Pharma. I pointed out a number of them and gave a view that the piece was close to worthless – but that the editor might try an interesting experiment. Why not ask the company to post the full dataset linked to this trial in exchange for the privilege of posting in the British Journal? He either never had the nerve to ask the company or else was rebuffed and nevertheless went ahead and published.

Then on September 20^th came an invitation to write another 100 word piece – on Antidepressants. It took more than 6 weeks before something took shape. When it did after some polishing I finally felt happy:

“Isoniazid, reserpine, imipramine, atropine, stimulants, benzodiazepines, antipsychotics, fluoxetine, ketamine – all have antidepressant credentials. The word coined by Max Lurie has lost meaning; it’s a basket for acronyms. Psychiatry was the first branch of medicine to have specialist hospitals and journals, the first to adopt controlled trials, rating scales, and guidelines. The antidepressants beckoned us toward clinical neuroscience but have led to myth, hidden data, ghostwriting, more lives taken than saved, womb to tomb consumption, and an increased incidence of “depression” from 1 per 1,000 to 1 in 5 of us. Knowing when not to prescribe is the greatest art in medicine.”

The response was:

Dear David

Thank you, that’s excellent. I will show it to the Extras Editors for review and will get back to you with their decision.

A week later it was:

Dear David

The Extras Editor has reviewed your 100 words and is happy with it generally, but has some reservations concerning the phrase ‘more lives taken than saved’ – would it be possible to tone it down or omit it altogether? The Editor feels that 100 words is not a good place for a polemic and that we should present a consensus view held by the profession in general, which may not pertain to this particular phrase…  One other thing is that all the drugs mentioned in the text but Prozac are referred to by their generic names, shall we call it fluoxetine for consistency?

I responded:

Dear _____,

I can happily concede the switch from Prozac to fluoxetine but ‘more lives lost than saved’ is a completely evidence based position – I can provide all the data for this. It would simply not be possible to say the opposite. I didn’t think these pieces were aimed at giving a supposed consensus view – I had assumed they must inevitably be viewed as somewhat idiosyncratic.

[For the record the entirety of the placebo controlled trials database on antidepressants (over 100,000 subjects) shows an excess rate of deaths on antidepressants compared to placebo].

To which the reply on December 18^th was:

Dear David

I hope you are well. I am afraid I don’t have good news regarding your 100 words on antidepressants. The Editors have deliberated further on whether to publish it and decided they could not, unfortunately, publish it in its current form. We are very sorry for this outcome and are grateful for your time and efforts.

Wishing you a Merry Christmas and a bountiful New Year.

Almost anyone I know who goes to the United States these days is astonished by the level of fear there among anyone working in the mental health field – fear to express any criticism about drug therapies, a fear to lower doses, or reduce treatment cocktails from 5 or 6 drugs to 1 or 2. The land of the free and home of the brave seems anything but these days.

Things feel better than this in Britain but there is all the same a marginalization of “dissent” and a greying of the landscape. The British Journal of Psychiatry has become exceedingly grey – although its current edition has an opinion piece by Pat Bracken and colleagues.

Twenty-five years ago friends from North America thought Britain was in decline. They remarked how the country couldn’t even afford to mow the grass that grew on the verges of or in the central reservations of motorways. The place was looking scruffy.

“No, no,” I told them, “it’s a really clever idea. The country was being so intensively cultivated elsewhere that there was a real risk of a loss of biodiversity and letting strips of meadow flourish in the margins of motorways was a creative use of this land.” Most of them I’m sure didn’t believe me – some of them I know didn’t.

Britain still has flourishing meadow grasses and plants along its motorways, but its academia it seems cannot allow anything slightly “wild” to grow in the interstices of their journals.

This is at a time when the editors of major British journals in particular see fit to use their journals as a pulpit to pontificate (offer their personal non-consensus views) on issues, while at the same time increasingly denying other voices.

Perhaps we should give up the pretense that this is a Collegial Journal, a journal for Fellows and Members. Where’s the collegiality in getting missives from nameless Editors relayed through someone even though she was quite delightful.

The current Editor in Chief started his term of office by saying he was proud that the British Journal of Psychiatry published articles like that by Healy and Cattell on Ghostwriting in Medical Journals. While the current edition has a call to action by Bracken and colleagues, it also has one by Arthur Kleinman that refers to the need for a Global Mental Health movement. This is certainly a well-intentioned piece but probably offers one of the best examples there is of the capture of evidence-based-medicine by the pharmaceutical industry of which more in the New Year.

It was the “Merry Christmas” what did it.