I remember well when I first met Peter Gøtzsche. I was giving a talk in Copenhagen related to my book Anatomy of an Epidemic, in 2012, and during the question-and-answer period, a tall man stood up and spoke about wanting to further investigate this question of the long-term effects of psychiatric drugs. He then introduced himself, and I left that night feeling pleased about what had just occurred.
Peter Gøtzsche, the director of the Nordic Cochrane Center—and one of about 80 scientists who had founded the Cochrane Collaboration—was going to take a closer look at the “evidence base” for psychiatric drugs. This was precisely what I had hoped would happen when I wrote Anatomy of an Epidemic. In that book, I had set forth the argument that a thorough review of the research literature, which was composed of “evidence” of many types, led to a conclusion that psychiatric drugs, on the whole, worsened long-term outcomes, and this was true even for schizophrenia and other psychotic disorders.
That was a controversial idea, and now here was a researcher, known for his skill and expertise in conducting systematic reviews of medical therapies, promising to turn his attention to this very topic. Perhaps he would find reason to dispute the conclusion I had drawn, but at least he had found the question worthy of his time.
In 2013, Gøtzsche published his book Deadly Medicine and Organized Crime: How Big Pharma Has Corrupted Healthcare. Part of this book focused on the corruption of psychiatry by big pharma, and in a concluding chapter, he wrote this about psychiatric medications:
“I know some excellent psychiatrists who help their patients a lot . . . I also know that some drugs can be helpful sometimes for some patients, and I am not antipsychiatry in any way. But my studies in this area lead me to a very uncomfortable conclusion. Our citizens would be far better off if we removed all the psychotropic drugs from the market, as doctors are unable to handle them. It is inescapable that their availability creates more harm than good.”
I felt vindicated by that statement, but more to the point, it made for a moment of hope. Now that Gøtzsche had come to this conclusion, it was certain to bring greater societal attention to this question of the long-term effects of psychiatric drugs, and how current use of these drugs has impacted public health at a societal level.
I also appreciated the nuances in his statement. He knew some excellent psychiatrists; he knew that the drugs can be helpful for some patients; and the conclusion he had come to made him “uncomfortable.” And his statement was not actually about whether the drugs were good or bad, but rather that doctors did not know how to properly use them, and that this improper use, at a societal level, “creates more harm than good.”
Since that time, I have spoken at conferences organized by Gøtzsche, and our paths have often crossed at conferences where we were both invited to speak. He often writes on Mad in America, and we are both on the board of the International Institute for Psychiatric Drug Withdrawal. As such, I knew that for the past few years he had increasingly run into difficulties with some members of the leadership of the Cochrane Collaboration, and during the past year, he had often complained that the leadership was seeking to boot him from the organization. But I never thought that would actually happen.
The reason for my confidence that he would survive this turmoil was that the Cochrane Collaboration had a reputation for publishing systematic reviews that challenged conventional wisdom and practices. That was an organizational point of pride that would, I thought, ultimately make it protective of Gøtzsche. And when, in early 2017, he was elected to the collaboration’s governing board with the most votes of any candidate, I figured that he had the necessary political capital to survive whatever fight he may have been having with Cochrane CEO Mark Wilson and other organizational leaders.
But now that Gøtzsche has been “expelled” from the collaboration, removed from the governing board by a 6-5 vote, and ousted as a contributing member of the organization, I am slapping the side of my head, and wondering why I ever thought it would be otherwise. In his public statements about psychiatric practices and its treatments, Gøtzsche had publicly donned the cloth of the heretic, and there is a long history, at least in this discipline of psychiatry, of heretics being booted from the tribe, or at least sent out to pasture. Loren Mosher, Peter Breggin, and David Healy are some of the more familiar names that tell of such banishment.
The specific reason put forth by the Cochrane leadership is that its expulsion of Peter resulted from complaints about his “behavior.” Peter is a strong personality, and I am sure he can rub some colleagues the wrong way, which I suppose gets collected into a complaint about his “behavior.” Yet, irritating his colleagues is not an offense that, under Cochrane rules, could get him expelled, and thus the official complaint by the Cochrane leadership is that Gøtzsche, in his public statements, had repeatedly failed to make it clear that his opinions were his own, and not the opinions of the Cochrane Collaboration.
Gøtzsche, as he has mounted his response, is not claiming that he was ousted because of his views about psychiatry. He is attributing his ouster to his criticisms of Cochrane CEO Mark Wilson and other leadership for the moral failure of their “business model” and the ties of many Cochrane reviewers to the pharmaceutical industry. However, if you read the report of the “independent person” appointed by the Cochrane collaboration to investigate this conflict, it’s clear that the complaints about Gøtzsche’s “behavior” were very much tied to his vocal criticisms of psychiatry. The Cochrane leadership wanted to distance itself from his criticisms, and, in essence, make it publicly known that it didn’t agree with him.
At least from this perspective, Gøtzsche’s ouster is a betrayal of what might be called the scientific enterprise, which is a collective social good. The Cochrane Collaboration, by failing to resolve this dispute in some other way, failed in its mission to serve as a collaboration of scientists that would, in their reviews, dare to challenge conventional medical wisdom. In order to stay true to that mission, the Collaboration needed to be protective of “heretics” in its midst.
The Cochrane Legal Review
The Cochrane Collaboration hired Thomas Grant to conduct a “formal legal review” of the complaints made against Gøtzsche, and to also review Gøtzsche’s complaint against the Cochrane CEO Mark Wilson. Grant completed his “preliminary report” on September 12, 2018.
Here is how Grant describes Gøtzsche’s work as a scientist:
“It is clear that Peter Gøtzsche is an academic of very considerable eminence who has published widely. He is known for the vigorous espousal of views which some might describe as controversial. (I do not mean this in any way pejoratively.) I do not believe that the sincerity of his views and the rigour and quality of his academic work is in issue.”
This is a critical point: The expulsion had nothing to do with Gøtzsche’s work as a scientist. The reviewer, in his report, praises Gøtzsche for the “rigour and quality of his academic work,” and as an “academic of very considerable eminence.” This is to say that his scientific work is of the very kind that burnishes the image of the Cochrane Collaboration as a first-rate scientific organization.
Grant states that the first time there was a complaint against Gøtzsche was in 2003 (ten years after Gøtzsche, along with 80 others, founded the Cochrane Collaboration). That complaint arose because he had published several papers critical of the quality of some Cochrane reviews, and while doing so, he had listed the Nordic Cochrane Center as “his professional address,” which, for some reason that isn’t made clear in the report, was deemed improper.
Thus, this first complaint arose because of Gøtzsche’s criticism of Cochrane itself, which ruffled some feathers. Moreover, the specific nature of the complaint posed an obvious Catch 22 dilemma for Gøtzsche. He had founded the Nordic Cochrane Center, and was its director. That was in fact his “professional address.” So if he wasn’t supposed to list this position when he published research articles and spoke to the public, what position could he give? Peter Gøtzsche, gadfly?
The next “behavioral” problem listed by Grant is the “2014 Book issue.” In a letter to Gøtzsche, Wilson and other Cochrane leaders complained that in his book Deadly Medicine and in a subsequent video, he had “appeared to advocate that every patient taking psychotropic medication should stop taking their psychotropic medication and that they would be healthier if they ceased to take the medicine.”
“You are aware this is a highly charged and sensitive issue,” Wilson and the others wrote. “We have had representations from individuals and organizations asking whether Cochrane supports your views on this matter.” They added that while Gøtzsche was free to express his opinions, in the future he needed to make it clear that “his personal views were not presented in any way such that they could be perceived to represent the Cochrane view.”
Here is what we can see at this moment: In his first twenty years with Cochrane, there were two times that complaints were made against Gøtzsche regarding his use of his professional title, and each time it was after he published criticisms that upset people within the organization. There apparently had never been an issue of his using his professional title, as director of the Nordic Cochrane Centre, when his comments weren’t upsetting others within the organization.
After that book-related warning, Gøtzsche continued to speak critically of psychiatry, and the feud continued to escalate. On one occasion, the Cochrane leadership publicly declared that Gøtzsche’s views were his own and not those of the Cochrane group, a declaration that Gøtzsche rightly understood to be an attack on his credibility, raising the rancor another notch. Finally, in a letter dated June 9, 2015, CEO Wilson and others told Gøtzsche that he was “not to use his title of ‘Director, Nordic Cochrane Centre,’ unless speaking or writing directly about Cochrane projects.”
The “violation of rules” excuse for expelling Gøtzsche had been set. In his review, Grant cites a number of times that the Cochrane leadership was upset by Gøtzsche’s public comments about psychiatry that were made while he was using his title of Director of the Nordic Cochrane Center. To wit:
- In January 2014, he wrote an article in a Danish newspaper, Politiken, about the “Ten Myths About Psychiatric Drugs,” which angered Danish psychiatrists and health professionals.
- In a “Maudsley” debate in London over whether psychiatric drugs did more harm than good, Gøtzsche argued that, based on his review of mortality data, psychiatric drugs are the third leading cause of death; and that societies would have a “healthier and more long-lived population” if they only used 2% of the psychiatric drugs they currently used.
- In September 2015, in conjunction with the publication of his new book, Deadly Psychiatry and Organised Denial, Gøtzsche published an article in the Mail Online that, according to the headline, told of how “side-effects of drugs taken for insomnia and anxiety kill thousands.”
The most “recent issue” related to psychiatry, Grant wrote, was a complaint from E. Fuller Torrey. Gøtzsche had written to Torrey requesting information about deaths in the Norwegian TIPS study, which had been funded in part by the Stanley Medical Research Institute, where Torrey is associate director of research, and Torrey responded by filing a formal complaint against Gøtzsche. Torrey stated that Gøtzsche had presented himself as a “Protector for the Hearing Voices Network in Denmark,” an organization that—according to Torrey—promoted numerous false beliefs. As a result of Gøtzsche’s relationship with this organization, Torrey wrote, “I would personally not find any Cochrane publication on mental illness to be credible.”
Finally, in his report, Grant noted that Gøtzsche had written a letter of complaint, on Cochrane Nordic letterhead, to the European Medicines Agency regarding its assessment of the safety of vaccines against the human papilloma virus, and that also may have violated the organization’s “Spokesperson policy.”
While the vaccine-related complaint may have been the final straw for the Cochrane leadership, at the heart of Grant’s review is this charge: Gøtzsche, while presenting himself as Director of the Nordic Cochrane Centre, had made public comments about psychiatry that CEO Wilson and other leaders of the Cochrane Collaboration had found objectionable, and the fact that he had presented himself to the public as the director of the Nordic Cochrane Center while making such comments, which he had been asked not to do, became the Collaboration’s “reason” for expelling him.
The Heresy Deconstructed
Since publishing his book Deadly Medicine in 2013, Gøtzsche has published a number of peer-reviewed research articles on psychiatric drugs related to their efficacy (or lack of efficacy) and adverse effects (such as raising suicide risks and mortality risks). Those articles list his professional address as Nordic Cochrane Centre, but there was nothing in Grant’s review about this published research.
Here is a brief look at Gøtzsche’s public comments that were seen as objectionable.
- He “appeared to advocate” that psychiatric patients stop taking their drugs.
The key phrase here is “appeared to advocate.” That “appeared” tells you that Gøtzsche actually never did advocate such a thing. In his book, he wrote that he knew that “some drugs can be helpful sometimes for some patients.” He said the harm came because “doctors don’t know how to handle the drugs,” and that because of that medical practice, society would be better off if the drugs were pulled from the market. He didn’t advocate that “every patient” stop taking the drugs; he was saying that the medical profession, in their use of the drugs, was causing harm.
- He wrote “Ten Myths About Psychiatric Drugs.”
It is easy to see why this publication would anger many within psychiatry, as it basically describes psychiatry, as an institution, peddling a number of falsehoods—such as the chemical imbalance story—to sell its products. However, it is hard to find anything in this article that is scientifically inaccurate. Gøtzsche wrote that the drugs do not fix chemical imbalances; that they are not like insulin for diabetes; that SSRIs have been found to increase the risk of suicidal behaviors in children and adolescents; and so forth.
- He wrote that “psychiatric drugs are the third leading cause of death.”
This statement was published in the BMJ, with Gøtzsche setting forth the evidence that supported his conclusion. He was making an argument within a scientific setting.
- He stated that we would have healthier populations if we only used 2% of the total amount of psychiatric drugs used today.
This may have been seen by Cochrane’s leaders as Gøtzsche’s most outlandish statement, but it logically follows from a conclusion that, on the whole, psychiatric drugs cause more harm than good. Indeed, all the markers for the public health burden of psychiatric disorders have increased since 1987, when Prozac was introduced, and thus it makes sense to argue that reducing the use of these drugs would lead to better societal health. (In his 2015 book Deadly Psychiatry and Organized Denial, he provided a rationale for how he came to the 2% figure.)
In short, Gøtzsche’s comments did have a scientific foundation and logic. But taken together—and uttered in the declarative style that Gøtzsche is known for—they constituted a wholesale attack on psychiatry’s current practices, and this apparently was too much for Wilson and other leaders of the Cochrane Collaboration. Gøtzsche had gotten along well enough with the Cochrane Collaboration during his first 20 years as director of the Nordic Cochrane Center, but then he made these public comments, and suddenly the Cochrane Group was insistent that he stop listing his directorship of the Nordic Cochrane Center as his professional address.
That is a timeline that belies the claim that Gøtzsche’s expulsion was simply because of his behavior; instead, it shows that his “behavior” came to be perceived as a problem once he became a sharp critic of psychiatry.
The E. Fuller Torrey Complaint
The complaint by E. Fuller Torrey is revealing, for it highlights this dynamic within psychiatry: You can be a leading figure who makes public statements that are belied by science but consistent with psychiatry’s disease model ideology, and you will suffer no harm or consequences; yet psychiatrists and other medical professionals who publicly prick holes in that story do so at great professional risk.
The TIPS study in Norway reported on the 10-year outcomes of 281 first-episode psychotic patients. In 2012, the researchers reported that 11% had died during this period. The precise number of deaths seemed to vary in three articles published about the study, but the 2012 article listed 31 deaths, and since the researchers lost track of 79 of the 281 people before the ten years were up, this meant that the death rate—among the cohort followed for 10 years—was actually 15% (31 out of 202). Given that the average age of the patients at study entry was 29 years, this was a very high death rate. Gøtzsche wrote the lead author of the study, Wenche ten Velden Hegelstad, asking for more information about the causes of these deaths, but the author did not provide it. Gøtzsche and I then submitted a letter to the editor of World Psychiatry, where the article had been published, asking for details about these deaths. The journal declined to publish our letter. At that point, Gøtzsche wrote E. Fuller Torrey, asking that the Stanley Medical Research Institute, as one of the funders of this study, provide detailed information about the deaths. Gøtzsche wrote:
“We believe funders have an ethical obligation to ensure that information, which is of great importance for public health, and which has been collected in the funded study, gets published. That would be a great service to psychiatry, the patients, and everyone else with an interest in this vitally important issue. When young people who are receiving antipsychotics die, we need to know why they died in order to reduce the risk of death in the future.”
Torrey responded not by providing such information, which would be the expected thing to do if you were following the dictates of good science, but by making a “complaint” about Gøtzsche to Cochrane CEO Mark Wilson. He said that Gøtzsche had identified himself as the Director of the Nordic Cochrane Center and as the “Protector of the Hearing Voices Network in Denmark.” This latter organization, Torrey wrote, promoted beliefs that were non-scientific:
- Auditory hallucinations are merely one end of a normal behavior spectrum, thus casting doubt on whether schizophrenia actually exists as a disease.
- Hearing voices are caused by trauma in childhood, for which there is no solid evidence.
The fact that Gøtzsche had a relationship with a group that promoted such ideas, Torrey wrote, showed a “clear lack of objectivity” by Gøtzsche, and for that reason he “personally would not find any Cochrane publication on mental illness to be credible.”
Torrey, with this complaint, was asserting that it was scientific malpractice to give credence to the beliefs of the Hearing Voices Network. Here is what a review of the science has to say about whether these beliefs have any merit:
- Studies regularly find that a significant percentage of people hear voices, including many who function fine. By one estimate, 75% of those who hear voices are not impaired in their lives.
- There have been numerous studies now that have found that trauma in childhood is a risk factor for hearing voices and developing psychotic symptoms later in life.
There is now a scientific trail to follow in this exchange. The lead author of the TIPS study doesn’t respond to Gøtzsche’s inquiry (bad science); the editor of the journal that published the article won’t publish a letter raising the question about the deaths (bad science); and the research director for one of the funders doesn’t respond to the question either (more bad science). Instead, he writes a letter of complaint to Cochrane CEO Mark Wilson, stating that since Gøtzsche has a relationship with the Hearing Voices group, he isn’t going to believe anything that the Cochrane Collaboration publishes about mental illness!
Torrey’s letter was clearly unhinged, and hardly one that the CEO of the Cochrane Collaboration could be expected to treat as serious, but Wilson, in a letter to Torrey dated March 2, 2018, basically threw Gøtzsche under the bus, stating that Gøtzsche had been warned to “distinguish sufficiently in public between his own research and that of Cochrane—the organization to which he belongs.” Wilson advised Torrey that he would consider his letter a “formal complaint.”
This is the moment in this dispute that perhaps is the most embarrassing of all for the Cochrane Collaboration. A director of the Cochrane Center wants to find out more about the deaths in a long-term study of psychotic patients, and the CEO of the Collaboration, rather than finding that pursuit worthwhile, finds reason to think it might provide cause to expel the director from the collaboration, and all because he receives a letter from an American psychiatrist that, even if one viewed it charitably, could best be described as disrespectful toward a users’ group, ignorant of the science, and silly in its threat to now see all Cochrane reviews related to psychiatry as lacking “credibility.”
You would think that all members of the Cochrane Collaboration would be red-faced upon knowing of this exchange.
The Loss for the Public
There are many within the Cochrane Collaboration that have rallied to Gøtzsche’s defense. Four members of the governing board quit in protest after the vote to oust him, and the 31 directors of Cochrane centers in Spain and Latin America have all signed a letter questioning his ouster. This has now evolved into a significant political struggle within Cochrane, although it is hard to guess how this will all play out.
Regardless of how it does, I am sure Gøtzsche will continue to speak his mind about psychiatric drugs, and will find a way to continue to research this topic. He is not going to disappear.
However, the future of the Cochrane Collaboration is less clear. Its reputation as an organization that fosters critical thinking is now stained, and that is the public’s loss. The medical literature—and this is particularly true of the literature in psychiatry—is already seen as corrupted and biased due to the influence of pharmaceutical money and guild interests, and now the public will have reason to question whether the work of the Cochrane Collaboration is similarly untrustworthy.
One would hope that the Cochrane group, as it moves forward, will remember that the public needs a collaboration that will provide a home for the “scientific” heretic, and that this decision to oust Gøtzsche betrays that value. Perhaps the Cochrane members can dig into their medical history books and read about Ignaz Semmelweis and his efforts to get other doctors to wash their hands before operating, and let that story of the medical community’s treatment of Semmelweis serve as a reminder of why it is important to provide such protection to the heretics in medicine. The Cochrane Group needs to remember that it serves the public, and this decision to oust Gøtzsche fails to fulfill that obligation.