APPENDIX 11
Memorandum by Critical Psychiatry Network
(PI 31)
BACKGROUND
The Critical Psychiatry Network is a group of
practising Consultant Psychiatrists based in the British Isles,
who are critical of orthodox beliefs in psychiatry, especially
the importance attached to biological interpretations of distress.
The Network first met in Bradford in January 1999, and seeks to
influence thinking and practice in the mental health field. We
are sceptical about the validity of the medical model of mental
illness. We disagree with the emphasis placed on biological research
and treatments. We do not seek to justify psychiatric practice
by postulating brain pathology as the basis for mental illness.
We believe that the practice of psychiatry must recognise the
primacy of social, cultural, economic and political contexts.
We welcome the Health Committee's inquiry into the influence of
the pharmaceutical industry in the NHS. It is timely given the
widespread public and professional concerns.
INTRODUCTION
The factual basis upon which our evidence rests
is that the great majority of common psychiatric conditions (such
as depression or psychosis) are unlike other medical disorders
in that there is no evidence to support the view that these
conditions are caused by underlying disturbances in brain function.
Psychiatric conditions are not medical condition like liver
or kidney failure, both of which have identifiable pathological
causes that predict treatment response and outcome. This has a
number of consequences:
1. Explanations of mental health problems
are strongly contested.1 Many service users reject the idea that
their problems arise from disordered brain chemistry to be rectified
by psychiatric drugs.
2. The problems of definition and validation
of illness in psychiatry means that the field is more open to
manipulation by commercial interest than other areas of medicine.2,
3
3. Psychiatry is unlike any other branch
of medicine in that patients may be compelled to take medication
for lengthy periods of time against their consent4. The government
is about to introduce new legislation to replace the 1983 Mental
Health Act, in which these powers of compulsion will be extend
into the community. This change in the law has major ethical implications.
It is absolutely essential that there should be no concerns about
the integrity of the factual basis of the evidence for the efficacy
or safety of drugs that are likely to be used in this way. All
the evidence indicates that this is not the case.
We must emphasise that we are not against the
use of medication in psychiatry. We use it daily in our work.
Our view is that there has to be a more rational basis for the
use of medication than is currently the case, one that is free
of commercial pressure and interest, and more honest about the
limitations and potential harm that medication can cause.
SPECIFIC POINTS
1. Drug innovations
Our view is that commercial rather than clinical
or scientific demands are becoming the dominant driving force
for "innovation", thus the popularity of cheaper "me
too" options, and the promotion of new "disease concepts"
to allow the re-badging of old products to expand markets without
major development costs.2 An example of the latter is the granting
of a product licence for the use of Fluoxetine for the treatment
of "premenstrual dysphoric disorder", a disorder constructed
to create a new niche for the drug as its patent was about to
expire. Other examples include social anxiety disorder and post-traumatic
stress disorder.
2. The conduct of medical research
Perhaps more so than any branch of medicine,
psychiatry is open to the influence of external interests, including
the pharmaceutical industry. This can be seen in the influence
that the industry has on the design, conduct and reporting of
psychiatric research, which all serve to promote the sponsor's
drug in the most favourable light.5, 6 This has major implications
for the design, conduct and interpretation of scientific studies
of the efficacy of drugs in psychiatric conditions. There are
high levels of media and public concern specifically about the
influence of commercial interest on scientific knowledge, specifically
in relation to side effects of the SSRI class of drugs.
3. Provision of drug information and promotion
We are deeply concerned about the influence
of pharmaceutical company representatives in shaping the opinions
of mental health professionals through promoting their companies'
products. We believe that they have an inordinately powerful influence
in this respect. Their work represents the triumph of the science
of marketing over the marketing of science. We believe that the
health service and general public needs to be better informed
about the modus operandi of pharmaceutical company representatives.
We believe that the interests of the public
would be better served in this respect if Trusts had clear policies
dealing with the relationships between clinical staff and representatives.
For this reason we have recently undertaken an audit of all 83
mental health trusts in England by letter addressed to each Trust's
chief executive. At the time of writing the response rate is 73%.
The figures for the 61 respondents are as follows:
|
Have a policy in place
N (%)
| Draft policy
N (%)
| Considering a policy
N (%)
| No plans
N (%)
|
|
| 32 (52%) | 9 (15%)
| 14 (23%) | 6 (10%)
|
|
The Health Committee will no doubt be aware of growing trend
to introduce nurse prescribing in the NHS. We broadly welcome
this development, but we believe that it makes the introduction
of clear policies regarding contact with pharmaceutical company
representatives even more important. It is known that representatives
"groom" community psychiatric and ward nursing staff,
especially when psychiatrists working closely with these nursing
colleagues will not see representatives. Our view is that very
close scrutiny must be made of the possible influence that representatives
may have upon nursing colleagues in this respect. There must be
very tight policies governing the type of preparations to be prescribed
by nursing staff, particularly with regard to new drugs. All Trusts
must have agreed policies that specify what is and what is not
acceptable in terms of the relationship between clinicians and
representatives.
For these reasons, our view is that pharmacists working in
the NHS, especially specialist pharmacists working in mental health,
are a more appropriate source of impartial advice about pharmacotherapy
for people with mental health problems. Mental health specialist
pharmacists have a thorough understanding of the mode of action,
effectiveness, risks and side effects of psychotropic medication.
Although their sources of information are culled from the industry,
they are (or should be) removed from the immediate commercial
interests that drive the work of company representatives. They
are thus better placed to appraise the claims made for the effectiveness
of different drugs.
We are also deeply concerned about the growing trend for
direct to consumer advertising, not out of the need to protect
professional interest, but because it is in the interests of the
pharmaceutical companies to shape the way the public understands
emotional distress in order to market their products. We cannot
overstate the power and influence of the pharmaceutical industry
in alliance with influential elites (like psychiatrists) in this
respect.
4. Professional and patient education
Biological explanations of mental disorder dominate contemporary
psychiatry,7 despite the absence of convincing evidence that conditions
such as depression and schizophrenia have a biological basis.
The education of psychiatrists continues to stress the importance
of concepts such as schizophrenia, despite the overwhelming evidence
that the concept is seriously flawed.8 In our view one of the
main reasons for this is that it serves the interests of the pharmaceutical
industry.
We draw your attention to an important paradox here. Government
policy in the health service has rightly attached particular importance
to social and contextual factors 9, and the democratic ideals
of greater public involvement in the health service. This is of
particular importance in psychiatry, where many service users
feel alienated and excluded from society,10 especially those from
our Black and Minority Ethnic communities.11 Despite this, the
education and training of psychiatrists, arguably the single most
powerful and influential group of professionals in mental health
services, is dominated by biological accounts6 that are incapable
of responding to the social, cultural and political realities
of many patients' lives.
5. Regulatory review of drug safety and efficacy
No comments.
6. Product evaluation, including assessments of value for
money
Economic evaluations often use measures derived from value
judgements, so it is very important that the researchers are impartial.
Economic evaluations funded by drug companies show their own products
favourably.12 The National Institute for Clinical Excellence (NICE)
does not appear to take into account the source of funding of
research studies that it cites in evidence for the efficacy of
drugs in producing its guidelines.
RECOMMENDATIONS FOR
ACTION
We believe the following actions are necessary:2
1. The use of monies from the pharmaceutical industry
to subsidise continuing medical education, both locally and nationally,
must be examined. Policies and procedures must be introduced in
discussion with the Department of Health, and bodies responsible
for postgraduate medical education, to minimise or eliminate the
use of such monies, at least for local teaching. This is a key
route of influence upon trainees.
2. If sponsorship is deemed essential, the use of
blind trusts should be investigated as an alternative to direct
sponsorship.
3. Declarations of interest must be strongly enforced.
The medical Royal Colleges should establish Registers of Members'
Interests, which require all members to disclose annually the
value of gifts and sponsorship received from drug companies. This
information must be in the public domain, along the lines of the
Register of Members' Interests in the House of Commons. If it
is acceptable and right that members of the public can access
their MP's business interests, we believe that the same standard
should apply to other public servants, such as members of the
medical and nursing profession.
4. Our view is that bodies like the Royal College
of Psychiatrists have a duty to ensure not only that its members
reach required educational standards, and that these standards
are maintained (continuing professional development), but also
that these standards are maintained alongside probity and transparency
in terms of potential conflicts of interest.
5. All NHS Trusts should have comprehensive policies
concerning sponsorship and the pharmaceutical industry. These
policies should set out what is and what is not acceptable in
the relationship between employees (ie all clinical workers, not
just medical staff) and the industry.
6. We are extremely concerned about the possible
influence of pharmaceutical company interests on government bodies,
especially NICE and NIMHE. These bodies must be unimpeachable.
They must be able to demonstrate that they are completely objective,
and free of potential sources of bias and conflicts of interest,
in the way they select and evaluate their sources of evidence.
Links between officers of these organisations and the industry
must be in the public domain. There must be no industry funding
for any aspect of the activities of these organisations.
REFERENCES 1 Bracken,
P and Thomas, P (2001) Postpsychiatry: A new direction for mental
health. British Medical Journal, 322:724-727.
2 Moncrieff, J, Hopker, S and Thomas, P (2002) The pharmaceutical
industry and disease mongering. British Medical Journal. 325,
216.
3 Moncrieff, J, Hopker, S and Thomas, P (2004) Psychiatry
and the Pharmaecuetical Industry: Who pays the piper? In press,
Psychiatric Bulletin, July 2004.
4 Thomas, P and Cahill, A (2004) Compulsion and psychiatry—the
role of advance statements. British Medical Journal, 329:122-3
5 Safer DJ (2002) Design and reporting modifications
in industry sponsored comparative psychopharmacology trials. Journal
of Nervous and Mental Disease, 190, 583-592.
6 Melander H, Ahlqvist-Rastad J, Meijer G, Beerman B
(2003) Evidence b(I)ased medicine- selective reporting from studies
sponsored by the pharmaceutical industry: review of studies in
new drug applications. British Medical Journal 326, 1171-1173.
7 Moncrieff J, Crawford M (2001) British psychiatry in
the twentieth century—observations from a psychiatric journal.
Social Science and Medicine, 53, 349-356.
8 See, for example, Bentall, R (2003) Madness Explained:
Psychosis and human nature. London, Allen Lane.
9 HMSO (2000) The NHS Plan: A Plan for Investment, A
Plan for Reform. Cm 4818-I, London, HMSO.
10 Sayce L (2000) From Psychiatric Patient to Citizen:
Overcoming Discrimination and Social Exclusion. Macmillan Press:
London.
11 P Walls and S P Sashidharan (2003) Real Voices—Survey
findings from a series of community consultation events involving
Black and Minority Ethnic groups in England.Report prepared
for the Department of Health September 2003.
12 Baker C B, Johnsrud M T, Crimson M L et al
(2003) Quantitative analysis of sponsorship bias in economic studies
of antidepressants. British Journal of Psychiatry 183,
498-506.
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