Friday, March 24, 2023

Comments by Marion Brown

Showing 28 of 28 comments.

  • Yes indeed. That BMJ ‘News’ article (quoted in full) was published this week – and perhaps others will also respond to the BMJ about it? If you click the link near the top of above post, you will see that some of us have had responses published, and have included link to the MIA article. The BMJ only publishes some selected responses. It feels important to take our discussion to the medical profession – so not to be just talking between ourselves but talking with the medical profession in a ‘mainstream’ medical journal.

  • Thank you to James for writing this – and to MIA for publishing.
    This has facilitated a couple of mentions/references published in BMJ rapid responses (to an 18 December BMJ ‘News’ article about ‘Treatment Resistant Depression’ – see below for full text).
    This is the full text of the BMJ article: (others can respond too! – via link above)
    Treatment resistant depression: what are the options?
    BMJ 2018; 363 doi: (Published 18 December 2018)
    Cite this as: BMJ 2018;363:k5354
    By Greta McLachlan (BMJ)
    Some patients with treatment resistant depression have tried up to 12 antidepressants and waited 10 years before they are seen at specialist centres, a recent press briefing heard. The figures fall far short of targets set out in draft guidance from the National Institute for Health and Care Excellence, which says that all patients who have not responded to two antidepressants should be referred to specialists.1
    NICE’s definition would mean that 2.7 million people in the UK have treatment resistant depression (between 10% and 30% of people with depression), an unmanageable number for the NHS’s psychiatric services.
    Allan Young, honorary consultant at Maudsley and Bethlem Hospitals in south London, told the briefing that though GPs were good at identifying and treating depression, “TRD [treatment resistant depression] is a subgroup—and there isn’t the capacity in secondary mental health teams to deal with this.”
    So what are GPs supposed to do? The answer it seems is, first, know the options and, second, know when to refer.
    Second line options
    After trying selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors, GPs could try the multimodal serotonin stimulator vortioxetine, said Young. If symptoms persist after an adequate dose and trial of this, patients should be reassessed for diagnosis, adherence, and other comorbidities, he said.
    Adding in psychotherapies such as cognitive behavioural therapy is the next option. If this is unsuccessful, adding an atypical antipsychotic, such as lithium, quetiapine, or aripiprazole, has been shown to be beneficial.2
    The thyroid hormone liothyronine (T3) is another effective adjunct second line treatment with few side effects.2 Although its price has risen 6000% over the past 10 years, from £4.46 for 28 pills in 2006 to £258 in 2017, it is still useful, said specialists.
    Tony Cleare, professor of psychopharmacology and affective disorders at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said that if GPs don’t think they are adequately trained to prescribe these drugs they should refer patients to specialist centres. And any patients about whom GPs have concerns or GPs believe are not coping with their depression should also see a specialist, said Young.
    “GPs used to ask me, ‘Who should we refer?’ You should refer people that you think need referring. It sounds a bit daft, but it’s the old gatekeeper model: if you refer everyone willy-nilly then the whole system will break down,” he said.
    On the horizon
    James Rucker, honorary consultant at the Maudsley and Bethlem Hospitals, says that there have been relatively few medical advances in depression treatment since fluoxetine (Prozac) hit the scene in the late 1980s.
    “As the pharmaceutical pipeline has run dry, people have looked to history for inspiration,” he said, pointing to investigations by his team at King’s College London into psilocybin.3
    In the 1960s psilocybin was marketed as a medicine by Sandoz (now Novartis) as a “catalyst” for people with treatment resistant depression. In a systematic review of clinical trials Rucker has shown that approximately 80% of patients who were given psilocybin showed clinical improvement.4 This did not mean “we are saying psilocybin is ‘safe,’” he said, or that it was an effective drug for treatment resistant depression, “but we are trying to work out if it is.”
    In 1970 psilocybin was made a schedule 1 drug in the UK, making it nearly impossible to use in clinical trials. The evidence that placed psilocybin into schedule 1 was “flimsy,” said Rucker, and public opinion on the drug is now shifting, making it possible for him to study psilocybin in the same way as all potential new medicines.
    It’s a situation similar to that of ketamine, although ketamine is still used routinely in hospitals and “field” settings such as conflict or disaster zones.
    A 1996 randomised controlled trial showed that ketamine had an almost immediate effect on treatment resistant depression. Patients’ symptoms improved within an hour, and the effects lasted for up to seven days. These results have been replicated numerous times, and ketamine is now being used to treat treatment resistant depression in specialist centres. It is delivered as an intravenous infusion, taking about an hour to administer.
    The drug company Janssen is trying to develop an intranasal ketamine spray, which would make the process of administration much quicker and cheaper.
    James Stone, of the Institute of Psychiatry, Psychology and Neuroscience, told the briefing: “[Our] Oxford clinic is overrun with people wanting ketamine treatment as their depression is so bad.”
    Ketamine spray could be available in the United States as early as next year, he said, and enter the European market two or three years later.
    However, neither ketamine nasal spray nor psilocybin would be take home drugs. They would still need to be administered in controlled environments, much like methadone is now, agreed the specialists.

  • Thanks very much to MIA for linking this article! And of course for support in getting our Scottish petition started! (a year ago now). This is our recent BMJ response (to the BMJ Editor’s topical roundup) – which summarises where we are up to with the Scottish – and Welsh! petitions.

    Official papers for the 1 May meeting of the Welsh Commitee can be found here:

  • Terrific article Sarah! Than you so much for writing it and all makes so much sense. I am so excited to see a new book by Robert Sapolsky too – his ‘Why Zebras don’t get Ulcers’ is an all-time favourite for me, and essential background reading for Human Givens approach (which I am trained in and operate from!).

  • Hello Merry – thank you for your comment! I guess that the process for a public petition depends on which country you are in – and we have found that the Scottish Parliament public petition process is quite unusual… and we will learn more as our own petition goes through the process here in Scotland.
    Perhaps you can explore what options are available to you in your own country? I have sent an email and am happy to share our own experience as it unfolds.

  • These are good points. Of course there are huge problems with the neuroleptics.
    The participants of our particular self-help group have mostly had experience of antidepressants and/or benzos only, taken as prescribed by general practitioners.
    We decided to focus this particular petition on antidepressants and benzos as these are so commonly prescribed, by general practitioners in UK, for the everyday symptoms of life ‘stress’ or distress (anxiety, insomnia, panic attacks, feeling miserable/depressed etc.)
    We know that these first-line medicines can cause further problems including psychosis … leading on to further psychiatric and other medications being prescribed.
    So… we wanted to raise awareness that these very commonly prescribed medicines – which in the case of antidepressants are still very widely believed by doctors and the pubic to be ‘safe and effective’ and ‘non-addictive’ – are causing a great deal of harm and illness, especially when taken over the long term.

  • Thank you very much MIA for sharing this – and thank you to people who have signed our petition! We are intending that this initiative will have much wider influence than just in Scotland and the support from people globally clearly illustrates the global nature of the issues raised around the harms of these prescribed medicines. If anyone has trouble signing the Petition or leaving a comment, these can be emailed to [email protected] (Ref PE01651) for manual upload during manned office hours.

  • Philip – you make very important points and we keep asking ourselves ‘how can this be?’

    I have come to see for myself that prescribing family doctors (especially) are being actively misled to mis-diagnose side-effects, adverse effects, withdrawal and/or long-term effects of antidepressants (and other psych meds) as ‘medically unexplained symptoms’ (MUS)/somatic system disorders. This MUS diagnosis seems to be a very convenient hiding-place for all manner of neurological dysfunctions/damage of unknown origin …. and a way to divert attention and ‘re-attribute’ very serious patient suffering to yet another DSM/ICD ‘diagnosis’. Patients are being made ill/disabled and then having their credibility completely undermined. The more that they try to draw attention that something is terribly wrong – the more that they find themselves labelled as ‘difficult’ ‘attention-seeking’ ‘heart-sink’ patients demonstrating ‘excessive health anxiety’.

    I do not know where psychiatrists, neurologists, healthcare providers, politicians and insurance providers etc. sit in all this, but I do know that patients are being very seriously harmed. And every single day countless more unsuspecting people are starting on these medicines …

    I have been writing about this recently, trying specifically to reach UK family doctor readership:—a-serious-concern

    Perhaps I can share this too – as a wry look at what is going on, largely below the radar, and not only in UK!

  • James et al

    I have recently come across another questionnaire, introduced around the same time as PHQ-9 and GAD-7 and also in association with Pfizer. This is the PHQ-15, used together with the other two questionnaires to help to ‘diagnose’ medically unexplained symptoms (MUS), also known as somatic system disorders …. Here’s links to the PHQ-15 questionnaire:
    (more about it wrt DSM5 in this download )

    I have to say that I find this very alarming altogether – and seems to confirm my earlier observation

  • Thank you James Davies (for the excellent new book and for this article) – and James Moore for speaking on Radio 5-live!
    Many other people had contacted the programme with their stories and other input too… so it will be interesting to see if they do put together a further programme on the topic.

    And then there is the off-label prescribing of antidepressants – as featured in a new BMJ editorial this week and which is most alarming too.
    I have contributed a rapid response – others may wish to as well?

  • I would suggest we consider what is the chicken and what the egg? If we consider emotional distress states such as depression, anxiety, insomnia etc. as our natural ‘alarm systems’ – alerting us that something is not working, either in our emotional lives or in our physical systems functioning, then treating ‘depression’ with medication is akin to overriding these alarms … and has consequences.
    I write about this in my recent MIA blog

  • These studies never seem to specify whether people have been on medication for their ‘mental health’ diagnoses – in fact the very fact they these have been ‘diagnosed’ suggests that they will have been taking prescribed medication. My thinking on this article is detailed in my own recent MIA article observing the diagnosis of Medically Unexplained or Somatic Symptoms …

  • Thank you all for these comments. All very pertinent. What I am trying to do is to illustrate clearly how patients and doctors (who are also patients) are becoming misled and deluded by factors below the radar. I think many GPs will be horrified to realize that the NHS professional guidelines which they have to comply with are causing their patients to become effectively poisoned by these drugs. I have not come across anyone else, as yet, who has pointed out the apparent (to me) MUS/somatic disorder (another DSM diagnosis) connection…. This vague and wide-symptom psychiatric MUS/somatization diagnosis has the potential to be particularly damaging, cruelly undermining the doctor/patient trust relationship when patients are presenting with clear symptoms of being poisoned!

  • It seems that chronic fatigue and adverse effects (incl. withdrawal effects) of the medications have a lot in common – being ANS (autonomic nervous system) dysfunction … Of course adding in more medicines to the mix messes our functional ‘systems’ even more!