Formal Complaint to the UK Royal College of Psychiatrists

Patients, academics and psychiatrists formally complain that the president of Royal College of Psychiatrists has misled the public over antidepressant safety

London, UK – A formal complaint of misleading the public on a matter of public safety has today been lodged with the Royal College of Psychiatrists (RCP) against its President, Professor Wendy Burn, and the Chair of its Psychopharmacology Committee, Professor David Baldwin.

Burn and Baldwin stated, in a letter to The Times on 24 February, that: ‘[for] the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment’.

A formal complaint disputing this claim has been signed by 30 people, including 10 psychiatrists and 10 people who have experienced withdrawal effects from antidepressants for between eleven months and ten years.

It states: ‘To mislead the public on this issue has grave consequences. People may be misled by the false statement into thinking that it is easy to withdraw and may therefore try to do so too quickly or without support from the prescriber, other professionals or loved ones… Such irresponsible statements bring the Royal College of Psychiatrists, the profession of psychiatry (to which some of us belong), and – vicariously – all mental health professionals, into disrepute.’

The complaint cites several research papers documenting that withdrawal effects often last far longer than two weeks.  These include a survey of more than 800 antidepressant users conducted by the RCP itself, which found that withdrawal symptoms were experienced by the majority (63%), generally lasted for up to 6 weeks and that a quarter reported anxiety lasting more than 12 weeks.  These survey results contradict Burn’s and Baldwin’s letter yet were removed from the RCP website within 48 hours of the misleading statement being made in The Times.

Professor Sami Timimi, professor of psychiatry and member of the Council for Evidence-based Psychiatry commented: ‘It is shameful that the official body that represents my profession throws about dangerous and misleading statements like this that lack a credible evidence base. We should be warning people about the terrible experiences of withdrawal that patients may experience, not giving false reassurance.’

Professor John Read of the University of East London said: ‘It is unethical to minimise how very difficult many people find it to come off these drugs. Furthermore the RCP cannot rely on pharmaceutical industry-funded research when addressing the public on matters of drug safety, as we know it is susceptible to bias. In addition, the chair of the Psychopharmacology Committee should not be in receipt of pharmaceutical industry funds if they are to restore public trust.’

Another signatory to the complaint, James Moore, from Monmouthshire, added: ‘I have experienced antidepressant withdrawal effects for the better part of a year now.  I had no prior warning of the difficulties I would endure and it has been shocking to find how little support there is for people who have taken their drugs as prescribed but ended up in difficulty.  Sadly, I know from the many messages I receive that I am not alone in this struggle.’

The full letter is provided below and can be shared from the website of the Council for Evidence-Based Psychiatry along with a Press Release.

Professor Read has recently been interviewed for the Mad in America podcast and talks about the events leading up to this formal complaint.

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The Complaints Manager
The Royal College of Psychiatrists
21 Prescot Street
London E1 8BB

March 9, 2018

Dear Sir/Madam

We, the undersigned, respectfully submit to the Royal College of Psychiatrists (RCPsych) Disciplinary and Complaints Committee the following formal complaint against Wendy Burn, President of the RCPsych and David Baldwin, Chair of the RCPsych Psychopharmacology Committee.

We do so in accordance with clause 1.1.6 of the ‘Remit and Operation of the Disciplinary and Complaints Committee’ document (January 2016), as follows:

1.1.6 (vi) Handling complaints received under the College’s “Complaints against College Members or Associates” procedure: 1.1.6.1 This procedure relates strictly to complaints about the conduct of a Member or Associate of the College, or in relation to their work on behalf of the College or in association with the College. Examples include holders of any College office when acting in a College capacity (whether elected, appointed or co-opted), College representatives on Advisory Appointments Committees, as examiners, organisers of College meetings or delegates at College events.

After careful consideration we have decided to lodge our complaint with the RCPsych in the first instance, rather than immediately with the General Medical Council, because the behaviour in question, while performed by two individual psychiatrists, was undertaken while ‘acting in a College capacity’ (see above).

It is our hope that the College will take our concerns seriously and take steps to remedy the situation in a way that will preclude the need to take the matter forward to other bodies. Our goal is to correct a potentially dangerous misleading public statement and to prevent similarly misleading statements in future by representatives of the RCPsych, not to punish individuals.

The Complaint

On 24.2.2018 The Times published a letter signed by Professor Wendy Burn in her capacity as President of the RCPsych, and Professor David Baldwin in his capacity as Chair of the Psychopharmacology Committee of the RCPsych.  In that letter they made the following claim: ‘We know that in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment’

We believe that statement is not evidence-based, is incorrect and has misled the public on an important matter of public safety, with potentially hazardous consequences for members of the public.

On February 28^th, nine of us wrote to Professors Burn and Baldwin thus:

Dear Professors Burn and Baldwin

On 24.2.2018 The Times published a letter signed by you, in your capacities as President, and Chair of the Psychopharmacology Committee, of the Royal College of Psychiatrists (RCPsych).  In that letter you made the following claim: ‘We know that in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment’

We believe that statement is not evidence-based, is incorrect and has misled the public on an important matter of public safety.

Although more research may be needed before any definitive statements on this issue can be made we note that even the RCPsych’s own survey of over 800 antidepressant users, reported in the RCPsych document ‘Coming Off Antidepressants’, found that withdrawal symptoms were experienced by the majority (63%) and ‘…. generally lasted for up to 6 weeks’ … and that  ‘A quarter of our group reported anxiety lasting more than 12 weeks’.

We further note that within 48 hours of making your misleading statement in The Times you removed the ‘Coming Off Antidepressants’ document from your RCPsych website. One interpretation of this decision, and the timing thereof, is that you wanted to prevent the public seeing evidence that contradicts your claim in the Times.

We are considering lodging a formal complaint with the appropriate professional body about your misleading the public on a matter of public safety. In keeping with natural justice, however, we would first like to give you the opportunity to publicly retract, explain and apologise for the statement, in The Times and on the RCPsych website.  Alternatively please provide us with the research studies on which you based the statement that ‘in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment’.

We will await your response for one week before deciding whether to lodge the aforementioned complaint.

Please note that, as this is an urgent matter of public safety, we are making the concerns expressed in this letter public. We may also make public your response.

Yours sincerely

Dr John Read

Professor of Clinical Psychology, University of East London

On behalf of:

Dr Steven Coles (Clinical Psychology) Nottinghamshire Healthcare NHS Foundation Trust

Dr James Davies (Medical Anthropology) University of Roehampton

Dr Pieter Groot (Psychiatry) University of Maastricht

Professor Peter Kinderman (Clinical Psychology) University of Liverpool

Dr Hugh Middleton (Psychiatry) University of Nottingham

Professor Jim van Os (Psychiatry) University of Maastricht

Professor David Pilgrim (Clinical Psychology) University of Southampton

Professor John Read (Clinical Psychology) University of East London

Professor Sami Timimi (Psychiatry) Lincolnshire Partnership NHS Foundation Trust

 

We received the following responses within the specified seven day period:

 Good afternoon John. I do not believe we have met before. I find your letter somewhat hostile which is regrettable when we are both obviously concerned to make sure depressed and anxious patients receive the best possible care.

 I have no input into what the College does or does not do in terms of its factsheets and so cannot comment on that part of your message.

But you might be interested to read the two attached papers which explore the issue of symptoms occurring after either abrupt or tapered discontinuation of some antidepressant drugs. The staggered double-blind discontinuation design is helpful in evaluating potential problems.

 best wishes – David Baldwin

Professor of Psychiatry and Head of Mental Health Group, University of Southampton Faculty of Medicine

 Dear John

Like David I have not met you and also like him I find the tone of your letter surprisingly hostile when we all have the same aim which is to help our patients recover.

The leaflet that you refer to expired in 2016 and should have been revised then. It was based on a self-selecting survey and was never intended to stand alongside peer reviewed research which is what we now base our leaflets on.

This is an important area and we will produce a revised information leaflet with input from patients and, of course, the Royal College of GPs who see so many patients with mental health needs.

I recently had a very productive meeting with Nicola Gale, President of BPS, and we have committed to working more closely together. I think this is an area where input from BPS will be invaluable.

Best wishes

Wendy
Professor Wendy Burn
President, Royal College of Psychiatrists 

There has been no retraction of the misleading statement, or any comment at all from either Professor Burn or Professor Baldwin about the request for retraction. Furthermore, we have been provided with no evidence from either Professor to support their ‘two weeks’ claim. Professor Burn made no attempt to support the statement. Professor Baldwin attached two research papers, but neither was relevant to the question at hand (see Appendix).

Given the inadequacy of these responses we feel obliged, on behalf of the public, to lodge this complaint in the hope that others at the College will take responsibility for publicly retracting, explaining and apologising for the statement, in The Times and on the RCPsych website.

To mislead the public on this issue has grave consequences. People may be misled by the false statement into thinking that it is easy to withdraw and may therefore try to do so too quickly or without support from the prescriber, other professionals or loved ones. Other people, when weighing up the pros and cons of starting antidepressants may make their decision based partly on this wrong information. Of secondary concern is the fact that such irresponsible statements bring the College, the profession of Psychiatry (to which some of us belong), and – vicariously – all mental health professionals, into disrepute.

Recommendations

Whether you decide, having investigated our complaint, on Censure, Admonition, Suspension of Membership or none of these, we respectfully request that the following courses of action be taken by the RCPsych, in the public interest:

1. Publicly retract, explain and apologise for the misleading statement, in The Times and on the RCPsych website.
2. Provide guidance or training for all RCPsych spokespersons, including the current President, on (i) the importance of ensuring that public statements are evidence-based, and (ii) the limitations of relying on colleagues who are in receipt of payments from the pharmaceutical industry (e.g. Professor Baldwin)
3. Review policies and procedures relating to the holding of positions of responsibility within the RCPsych by members who are in receipt of drug company payments, including Professor Baldwin.
4. Provide new evidence-based information about antidepressants and adverse effects, including withdrawal effects, and guidance about how best to withdraw, to be issued by the RCPsych and generated and agreed on the basis of a joint working group including some of ourselves and withdrawal sufferers.
5. Reinstate, on the RCPsych website, the document ‘Coming Off Antidepressants’, including the results of the survey that contradicts the false statement and accurately reflects the experiences of over 800 antidepressant recipients.
6. Make a commitment to advocate for more research, using a range of methodologies, into the duration and nature of symptoms following withdrawal from antidepressants, and into tapering protocols and treatments to assist people to withdraw safely.
7. Arrange an informal roundtable meeting with Professors Burn and Baldwin and one or two other RCPsych representatives (perhaps chosen jointly by the Disciplinary and Complaints Committee and the President) with an equal number of ourselves, with the goal of moving on from a complaints procedure, and the difficult feelings involved therein, in such a way that we are all genuinely working together, in our inevitably different ways, to, in the words of Professors Burn and Baldwin in their responses above ‘help our patients recover’ and to not only ‘make sure depressed and anxious patients receive the best possible care’ but also those withdrawing from antidepressants.

As was the case for the initial letter to the two Professors, we are making this complaint public as it is an urgent matter of public interest. We are not prepared to let the misleading statement stand uncorrected or to have those who already know that it is misleading think that nobody in the mental health field cares or is prepared to act to correct it.

Please acknowledge receipt of the complaint and inform us, via Professor Read ([email protected]) as to the procedures you intend to follow, the timeframe thereof, and whether you require any more information from ourselves that may assist you in your investigations.

Yours sincerely

Dr John Read

School of Psychology

University of East London

On behalf of:

Claire Ashby-James (had withdrawal effects from Escitalopram for 1 year, 9 months)

Berkshire

Emeritus Professor Mary Boyle (Clinical Psychology) University of East London

Dr Pat Bracken (Psychiatry) County Cork

Dr Steven Coles (Clinical Psychology) Nottinghamshire Healthcare NHS Foundation Trust

Dr James Davies (Medical Anthropology) Council for Evidence-Based Psychiatry

Dr Duncan Double (Psychiatry) Norfolk and Suffolk NHS Foundation Trust

Tabitha Dow (withdrawal effects from Venlafaxine – 2 years, 4 months) Berkshire

Dr Peter Gordon (withdrawal effects from Paroxetine – 4 years) Stirlingshire

Professor Peter Gøtzsche (Medical Research) Director, Nordic Cochrane Centre

Dr Peter Groot (Psychiatry) University of Maastricht

Dr Christopher Harrop (Clinical Psychology) University College London

Carina Håkansson (Psychotherapy) International Institute for Psychiatric Drug Withdrawal

Ann Kelly (withdrawal effects from Fluoxetine & Venlafaxine – 10 years) West

Dunbartonshire

Professor Peter Kinderman (Clinical Psychology) University of Liverpool

Stevie Lewis (withdrawal effects from Paroxetine – 4 years) Monmouthshire

Nora Lindt (withdrawal effects from Venlafaxine – 3 years) Dublin

Dr Hugh Middleton (Psychiatry) University of Nottingham

Luke Montagu (withdrawal effects from Venlafaxine – 8 years) London

James Moore (withdrawal effects from Mirtazapine – 11 months) Monmouthshire

Sinead Morris (withdrawal effects from Paroxetine – 3 years) County Antrim

Professor Jim van Os (Psychiatry) University of Maastricht

Danielle Park (withdrawal effects from Mirtazapine/Depakote – 4 years, 4 months) Kent

Dr Margreet Peutz (Psychiatry) CGG Brussels, Belgium

Professor Nimisha Patel (Clinical Psychology) University of East London

Professor David Pilgrim (Clinical Psychology) University of Southampton

Dr Clive Sherlock (Psychiatry) Oxford

Dr Derek Summerfield (Psychiatry) King’s College London

Dr Philip Thomas (Psychiatry) (retired, ex University of Central Lancashire)

Professor Sami Timimi (Psychiatry) Lincolnshire Partnership NHS Foundation Trust

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APPENDIX

1. FAILURE TO PROVIDE EVIDENCE TO SUPPORT THE ‘TWO WEEKS’ STATEMENT

We asked Professors Burn and Baldwin to publicly retract the statement or “provide us with the research studies on which you based the statement that ‘in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment’.”

Professor Burn made no attempt to provide any evidence in support of the statement.

Professor Baldwin attached two papers (Baldwin et al., 2006; Baldwin et al., 2007). It is unclear whether Professor Baldwin submitted the papers as evidence in support of the ‘two weeks’ statement’. He wrote: ‘But you might be interested to read the two attached papers which explore the issue of symptoms occurring after either abrupt or tapered discontinuation of some antidepressant drugs.’

Neither paper is relevant to the question at hand. Both are drug company funded studies, by Professor Baldwin. One is an individual research study and one is a review paper. Neither the individual study nor any of the studies in the review paper provide any data relevant to the question of how long withdrawal or ‘discontinuation’ symptoms last. They were all studies of the frequency and/or severity of withdrawal symptoms within a predetermined time period, typically one or two weeks, (comparing the sponsoring drug company’s product with other antidepressants).

In his 2006 paper Professor Baldwin had made the same claim as in The Times:

‘Although uncomfortable, these symptoms are usually short-lived, and typically resolve 1–2 weeks after stopping treatment.’

Although Professor Baldwin offers no references in this sentence to support his claim, it is conceivable that the references in his preceding sentence were intended to support the claim:

‘Recent studies (Rosenbaum et al., 1998; Hindmarch et al., 2000; Michelson et al., 2000) confirm that ‘discontinuation symptoms’ (e.g. dizziness, nausea, headache, sleep disturbance, irritability and lethargy) are not uncommon with selective serotonin reuptake inhibitors (SSRIs).’

None of these three studies, however, provide any data that addresses the question of how long withdrawal effects last. The studies measure effects for only 5-8 days, 5 days and 4-7 days. Furthermore, none of the three studies suggested that the withdrawal effects had ceased, or were decreasing, during these short time periods. One, at least, clearly found the opposite:

‘These symptoms increased in severity and number throughout the five day interruption period’ (Michelson et al., p. 365)

2. EVIDENCE THAT THE TWO-WEEKS STATEMENT IS FALSE

A more recent review (Fava et al., 2015), of 15 randomized controlled studies, 4 open trials, 4 retrospective investigations, and 38 case reports, concluded that withdrawal symptoms ‘typically occur within a few days from drug discontinuation and last a few weeks. However, many variations are possible, including late onset and/or longer persistence of disturbances.’ For example, the review found two studies documenting the persistence of withdrawal symptoms up to one year following paroxetine discontinuation, and, also found, in relation to the same drug, that ‘Only in a few cases did symptoms spontaneously remit in about 2 weeks’.

The recent RCPsych survey of over 800 antidepressant users, published by the RCPsych in their document ‘Coming Off Antidepressants’ (recently removed from the RCPsych website), found that withdrawal symptoms were experienced by the majority (63%) and ‘…. generally lasted for up to 6 weeks’ … and that  ‘A quarter of our group reported anxiety lasting more than 12 weeks’.

A similar British survey found that 79 of 247 people (32%) who had succeeded in withdrawing from antidepressants took at least three months to do so, and 15% took at least six months (Read et al., submitted). The Nordic Cochrane Centre reviewed 45 papers on benzodiazepine addiction and 31 papers on SSRI ‘discontinuation syndrome’ and concluded that ‘Withdrawal reactions to SSRIs appear to be similar to those for benzodiazepines; referring to these reactions as part of a dependence syndrome in the case of benzodiazepines, but not selective serotonin re-uptake inhibitors, does not seem rational’ (Nielsen et al. 2012).

Additional, supporting evidence that the two-week claim is incorrect can be found in the consistent finding that high percentages of people, when asked directly, either report ‘severe’ withdrawal effects or experience the drugs to be ‘addictive, neither of which appears consistent with ‘unpleasant’ symptoms that are gone within 14 days.  A 2014 review of studies of ‘Patient-centred perspectives on antidepressant use’ found that ‘the most frequently mentioned reason for a negative opinion of antidepressants is that they may be addictive’ (Gibson et al. 2014). For example, of 192 people in the Netherlands who had been taking ADs for six months, 30% reported that antidepressants are ‘addictive’, with 30% also stating that ‘a person who starts taking antidepressants can never stop using them’ (Hoencamp et al. 2002). Of 493 antidepressant users in Denmark, 57% agreed with ‘When you have taken antidepressants over a long period of time it is difficult to stop taking them’ and 56% agreed with ‘Your body can become addicted to antidepressants’ (Kessing et al., 2005). Among 87 users in Scotland 74% reported that ‘antidepressants are addictive’ (Stone et al. 2004).

A 2017 British survey, conducted at Roehampton University, found the following results among 157 antidepressant users, all of whom self-identified as experiencing moderate or severe withdrawal, when asked ‘How long have you experienced withdrawal symptoms?’:

• up to a month – 14.6%
• two to three months – 17.8%
• four to twelve months – 26.1%
• one to three years – 9%
• more than three years – 18.5%

Thus the vast majority in this sample (85.4%) experienced withdrawal symptoms for at least two months.

The largest direct-to-consumer survey of antidepressant users to date found that 27% of 1,521 users in New Zealand experienced antidepressants to be addictive. More than half (55%) reported withdrawal symptoms and 46% of those described the withdrawal symptoms as ‘severe’ (Read et al., 2014).

An analysis of depression websites found many postings about withdrawal effects, including ‘severe headaches, shaking, electric shock feelings in their hands and feet, sweating, anxiety, shortness of breath, mental confusion, and severe depression’ (Pestello & Davis-Berman 2008). Examples included:

‘I am currently trying to wean myself off of Venlafaxine, which honestly is the most awful thing I have ever done. I have horrible dizzy spells and nausea whenever I lower my dose’.

‘It took me almost two years to get off Paroxetine and the side effects were horrendous. I even had to quit my job because I felt sick all the time. Even now that I am off of it, I still feel electric shocks in my brain’

Finally, we point out that the RCPsych document ‘Antidepressants’ (not removed from the RCPsych website at the time of writing this) states:

‘Up to a third of people who stop SSRIs and SNRIs have withdrawal symptoms which can last between 2 weeks and 2 months. These include:

• stomach upsets
• flu like symptoms
• anxiety
• dizziness
• vivid dreams or nightmares
• sensations in the body that feel like electric shocks

In most people these withdrawal effects are mild, but for a small number of people they can be quite severe.’

REFERENCES

Baldwin, D. et al. (2006). A double-blind, randomized, parallel-group, flexible-dose study to evaluate the tolerability, efficacy and effects of treatment discontinuation with escitalopram and paroxetine in patients with major depressive disorder. International Clinical Psychopharmacology 21, 159-169.

Baldwin, D. et al. (2007). Discontinuation symptoms in depression and anxiety disorders. International Journal of Neuropsychopharmacology 10, 73-84.

Fava, G. et al. (2015). Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review. Psychotherapy and Psychosomatics, 84, 72-81.

Gibson, K. et al. (2014). Patient-centred perspectives on antidepressant use: a narrative review. International Journal of Mental Health Nursing, 43, 81-99.

Hindmarch, I. et al. (2000). Abrupt and brief discontinuation of antidepressant treatment: effects on cognitive function and psychomotor performance. International Clinical Psychopharmacology, 15, 305-318.

Hoencamp, E. et al. (2002). Patients’ attitudes toward antidepressants.  Psychiatric Services, 53, 1180-1181.

Kessing, L., Hansen, H., Demyttenaere, K. et al. (2005). Depressive and bipolar disorders:

patients’ attitudes and beliefs towards depression and antidepressants. Psychological Medicine, 35, 1205-1213.

Michelson, D. et al. (2000). Interruption of selective serotonin reuptake inhibitor treatment. British Journal of Psychiatry, 176, 363-368.

Nielsen, M. et al. (2012). What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors. Addiction, 107, 900-908.

Pestello, F. & Davis-Berman, J. (2008). Taking anti-depressant medication: A qualitative examination of internet postings. Journal of Mental Health, 17, 349-360.

Read, J. et al. (2014). Adverse emotional and interpersonal effects reported by 1,829 New Zealanders while taking antidepressants. Psychiatry Research, 216, 67-73.

Read, J. et al. (2018). Staying on and coming off: the experiences of 752 antidepressant users. Paper submitted. Based on data from Mind survey:

www.mind.org.uk/news-campaigns/news/better-support-needed-for-people-on-antidepressants-says-mind/#.WpqMfodpo5s

Rosenbaum, J. et al. (1998). Selective serotonin reuptake inhibitor discontinuation syndrome: a randomised clinical trial. Biological Psychiatry, 44, 77-87.

Stone, J. et al. (2004). What do medical outpatients attending a neurology clinic think about antidepressants? Journal of Psychosomatic Research, 56, 293-295.

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