UK Royal College Dismisses Complaint

On March 9, 2018, a group of thirty academics, psychiatrists and people with lived experience wrote to the UK Royal College of Psychiatrists to challenge public statements about antidepressant withdrawal made in The Times newspaper.

The Registrar of the college replied with a decision on the complaint on April 24, 2018 which resulted in a response by the thirty signatories to the original complaint. The full reply by Professor John Read and colleagues, a press release and a copy of the RCP’s dismissal letter are provided below:

Letter in reply to RCP from Professor John Read on behalf of thirty academics, patients and people with lived experience

1 May 2018

Dear Registrar

Thank you for your email – Outcome of Complaint CMP02/18 – in which you inform us that you have decided to dismiss as unfounded the Complaint that we submitted to the College on 9 March 2018.

It is vitally important that this issue is addressed successfully. It is also vitally important that the public receive accurate, unbiased, information (in this case about medication).

So, we cannot accept this decision and will need to consider our next steps.

You have outlined four ‘reasons’ for your decision:

1. It is part of the role of senior Officers of the Royal College of Psychiatrists to respond to important debates in the media.

This is true but irrelevant and not in dispute. Our Complaint has nothing whatsoever to do with whether senior officials should respond to public debates. Our Complaint is not an attempt to silence your officials, but to persuade them to desist from making misleading, unsubstantiated, and potentially dangerous statements to the public.

2. A letter published in a daily newspaper is necessarily short and will be edited by the letters editor should they feel so inclined.  It is not intended to be, nor should it be expected to be, a comprehensive appraisal of all research in this area of work with detailed references to academic studies.

Again, this is true, but irrelevant. For your statement to be meaningful the ‘research in this area of work with detailed references to academic studies’ that you claim Professors Burn and Baldwin would have cited had they had space, actually exists. We have twice asked for this research to be provided.

You imply (but stay short of stating definitively) that the letter was edited. Please either send us the unedited version or acknowledge that the letter was not edited.

3. The letter was consistent with recommendations set out by NICE, which are based on the best available evidence. NICE Clinical Guidelines state that when prescribing antidepressants doctors should advise patients that discontinuation symptoms are “usually mild and self-limiting over about 1 week”.  (Depression in adults: recognition and management Clinical guideline [CG90] Published date: October 2009 Last updated: April 2016

This is the only one of the four Reasons that comes close to actually addressing the Complaint. However, a one-sentence suggestion in a set of guidelines, does not constitute evidence. It merely indicates that the errors made by Professors Burns and Baldwin have been made elsewhere.

We assume that a responsible, professional organisation, before citing the NICE guidelines as a defence against a Complaint, would have examined the research documentation that accompanies these guidelines to be sure that there was indeed, as implied by reference to the ‘best available evidence’ in ‘Reason’ 3, some evidence to support either the NICE statement about one week or the Burns and Baldwin two week claim.  We wondered why the RCPsych has not provided the evidence that they implied lay behind the NICE statement. So we have looked. We found none. https://www.nice.org.uk/guidance/cg90/evidence/full-guidline-pdf-4840934509

If you have evidence that the NICE statement, and hence Professors Burns and Baldwin’s statement, is accurate, we ask, again, that you supply it.

Far more importantly, the Registrar, on behalf of the RCPsych, has misrepresented the NICE statement in question. The actual sentence (in bold below) is:

1.9.2.1.   Advise people with depression who are taking antidepressants that discontinuation symptoms[16]  may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug.Explain that symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly.’

The RCPsych has deleted the phrase ‘but can be severe, particularly if the drug is stopped abruptly.’  Moreover, by not ending the truncated sentence with ‘week …….  .’  the misrepresentation itself has been obscured, by purposefully creating the false impression that nothing had been left out of the sentence.

This is not a rejection of our complaint, it is a repeat of precisely the same offence that led to our Complaint in the first place: the minimisation of antidepressant withdrawal effects. To be clear; there is a NICE statement (cited in support) which states “… but can be severe…” and this important qualification has been omitted, leaving the deliberately misleading impression that NICE merely state that withdrawal effects are trivial. This compounds the offence and is a matter of grave concern.

4. The ‘coming off antidepressants’ webpage was removed because we received a query about the ‘coming off antidepressants’ webpage/leaflet prior to the Complaint.  The leaflet asked those coming off antidepressants for their feedback, this was self-selecting and out of date; we considered it was better to remove it and review this information thoroughly in the future.

This issue was not part of the Complaint itself and is, like ’Reasons’ 1 and 2, irrelevant (although one of the seven ignored recommendations was that the webpage be reinstated).

We note, however, that this statement appears disingenuous. The webpage was actually removed on February 26^th, within 48 hours of the misleading statement appearing in The Times (24.2), and within 12 hours of the Council for Evidence-Based Psychiatry tweeting (to Professor Burns), on February 26th, the following:

‘Two weeks of withdrawal? But your own study, published on your website, says’ generally six weeks’.

To be clear, then, the webpage was indeed removed prior to the complaint. But the webpage was removed after it was pointed out that the material on that webpage contradicted the statements of Professors Burns and Baldwin.

The ‘out of date’ reason is also highly questionable. We found, at the time of our complaint, over 50 documents on the RCPsych website that are either out of date or don’t have a review date but which have not been removed. Your comments would have some weight if all those pages had been removed. Given that it was merely the webpage that appeared to contradict Professors Burns and Baldwin that was removed, and removed immediately after this contradiction was pointed out, your argument is difficult to accept.

To withhold or suppress research evidence (the survey of over 800 antidepressant users) because it is potentially embarrassing to two senior officials who have made a public statement that is contradicted by that evidence, might be seen to position the RCPsych beyond the traditional parameters of scientific practice. To then present reasons for doing so which any impartial observer would consider to be misleading, in conjunction with the various other examples of misleading statements identified above, might be seen to position the RCPsych beyond the traditional parameters of professional ethics.

Your letter concludes, on the basis of the four ‘reasons’ dismissed above, that;

We therefore find no evidence that the statement in the Times was misleading or that it could bring the College into disrepute.

We wonder what evidence the RCPsych looked for, if any. The RCPsych has chosen to ignore, without comment, all the research evidence provided in the Complaint. A responsible professional organisation would, when presented with several pages of evidence that their senior officials are making misleading statements, at least consider, and comment on, that evidence.

Conclusions

For all of the reasons outlined above we cannot therefore accept the decision to dismiss our Complaint.

Furthermore, as a result of how our Complaint has been responded to we now have serious additional concerns, namely that the RCPsych may currently:

• Not be committed to the usual practice of basing public statements on evidence rather than personal opinion
• Be committed to the ongoing minimisation of the negative effects of psychiatric medications
• Be bringing into disrepute the profession of psychiatry, and, by implication, the mental health workforce in general, including all those psychiatrists who do believe in evidence-based medicine
• Have a complaints procedure that is either seriously flawed or, at best, non-transparent.

To address our uncertainty about the last point above, and to inform our decisions about next steps, including whether to lodge an Appeal, we need more information.

We believe that there may be two possible grounds for upholding an Appeal.

There may be ‘evidence of a procedural or administrative irregularity’ (or several) (see 5.11 of your complaint procedure); and we are not sure that you have meaningfully completed the required step of ‘Reviewing the complaint and supporting paperwork’ (4.4.1), because of your failure to respond to the research evidence we provided or to provide any yourselves.

Please, therefore, respond to the following questions, within 14 days.

1. When attempting to hand deliver the Complaint to the ‘Complaints Manager; in accordance with the RCPsych website, Professor Read was told that ‘there is no Complaints Manager’ and that ‘Complaints are dealt with by the head of the appropriate department’. The Complaint was therefore received by the Department of Strategic Communications. The head of that Department, however, subsequently emailed Professor Read to say it was ‘beyond the remit’ of his Department and would be dealt with by some other, unspecified, person. Who made the decision to take the process away from the head of Strategic Communications (and thereby away from normal process as described to Professor Read) and to create, instead, an ‘Acting Complaints Manager’?
2. On what basis, in accordance with what written procedure, was that decision made?
3. Who decided who the ‘Acting Complaints Manager’ should be?
4. What criteria were used in making that choice?
5. Who else has been involved in the investigation or has it been entirely the independent work of the ‘Acting Complaints Manager’ with no involvement or influence from anyone else?
6. What specific actions were taken in undertaking the investigation, and by whom?
7. Was anyone in receipt of drug company payments for the past ten years in any way involved?
8. Were Professors Burns and Baldwin interviewed? If so, why were the complainants not also interviewed, and not provided with the opportunity to respond to their statements?
9. How, and by whom, were the Complaint and supporting paperwork reviewed?
10. How, and by whom, was it decided that all the research papers clearly contradicting the ‘two weeks’ claim did not render the claim misleading?
11. Given that the Chair of the Board of Trustees is Wendy Burn, who is also the President and one of the two people about whom the Complaint was lodged, who would be involved in hearing an Appeal?
12. Would anyone in receipt of drug company payments for the past ten years be involved in hearing an Appeal?

We draw your attention to the fact that the RCPsych was described last week (26 April) in the House of Lords as an institution that ‘can mislead Times readers on a matter of public safety’ because of the statement at the heart of this Complaint.

Excerpt from Hansard:

On 24 February, the president of the Royal College of Psychiatrists and a colleague wrote in the Times that for, “the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment.” This statement has appalled a large number of psychiatrists and patients who have lodged a complaint with the RCP, including some who have experienced withdrawal effects for between 11 months and 10 years. Even the Royal College’s own survey of 800 users found that withdrawal symptoms generally lasted for up to six weeks, with a quarter reporting that anxiety lasted more than three months. If even one of our leading institutions can mislead Times readers on a matter of public safety, what hope do the Government have of explaining these things to the general public?

Finally, please note that our Complaint ended with the following:

“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”. . .  followed by seven recommendations.

We note that you have not even acknowledged these suggestions. Perhaps they are being considered by another section of the RCPsych?

We restate them here in the hope that they might provide a way forward for the RCPsych in re-establishing some trust with the public on this matter:

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.

Yours sincerely,

Professor John Read

On behalf of, and after consultation with, the 29 other signatories to the original Complaint.

*****

PRESS RELEASE                      FOR IMMEDIATE RELEASE

Letter of dismissal from the Registrar of the Royal College of Psychiatrists

Dear Professor Read

Outcome of complaint CMP02/18: not upheld

Following an investigation, I have decided to dismiss as unfounded the complaint you, and your colleagues, submitted to the College on 9 March 2018. The reasons for this are:

1. It is part of the role of senior Officers of the Royal College of Psychiatrists to respond to important debates in the media.
2. A letter published in a daily newspaper is necessarily short and will be edited by the letters editor should they feel so inclined.  It is not intended to be, nor should it be expected to be, a comprehensive appraisal of all research in this area of work with detailed references to academic studies.
3. The letter was consistent with recommendations set out by NICE, which are based on the best available evidence. NICE Clinical Guidelines state that when prescribing antidepressants doctors should advise patients that discontinuation symptoms are “usually mild and self-limiting over about 1 week”.  (Depression in adults: recognition and management Clinical guideline [CG90] Published date: October 2009 Last updated: April 2016 <https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#step-2-recognised-depression-persistent-subthreshold-depressive-symptoms-or-mild-to-moderate>.
4. The ‘coming off antidepressants’ webpage was removed because we received a query about the ‘coming off antidepressants’ webpage/leaflet prior to the complaint.  The leaflet asked those coming off antidepressants for their feedback, this was self-selecting and out of date; we considered it was better to remove it and review this information thoroughly in the future.

We therefore find no evidence that the statement in the Times was misleading or that it could bring the College into disrepute.

Yours sincerely

Registrar

*****

More on this story:

Interview with Professor John Read for the Mad in America podcast May 1, 2018

Complaint letter of March 9, 2018