Chris Van Tullekan’s programmes about medication for children were compelling, raised some excellent points, but ultimately were too eager to score points to count as a balanced account.
The shows were formed of two episodes but essentially 4 stories.
- ADHD and methylphenidate
- Fever and calpol
- Cow’s milk allergy and hypoallergenic formula
- Depression and SSRIs
In each episode two stories were interweaved- this did not help clarity, because whether intentionally or not, this gives the impression that criticisms in one half apply in the other, when there are important differences between the issues. So, in descending order of how much I agree with Chris, I’ll try to explain:
Fever and Calpol
This is uncontroversial. We should not reach for the medicine bottle whenever a child is distressed or a bit hot, but the sweet taste and ritual of caring have a powerful placebo effect. As long as you stick to recommended dose, all you’re doing is wasting money, you’re not causing harm, so while Chris is right here, I’m not sure it’s an issue to get too excited about. We all waste money on keeping our kids happy, after all.
Cow’s Milk Allergy and industry infomercials
Here there are some serious points made. The formula milk industry exist to shift product, and cow’s milk allergy has, like many conditions, criteria for testing that are pretty inclusive. The problem is that the (genuine) best test for CMA is to give hypoallergenic formula and see if the child gets better. There are a few ways in which this can lead to over-diagnosis. If the doctor gives into the temptation to be ‘the clever doc’ and gives a confident diagnosis of CMA prior to testing, if the child gets better during a trial of hypoallergenic formula, but for unrelated reasons, or if the child doesn’t get better but people persist in treatment rather than think again.
In such a delicate situation, needing critical thinking and sound handling of uncertainty, industry-funded and run education can be problematic both in presentation and practice. We may think that as doctors we are immune to marketing, but we’re really not. On the other hand, medical education would struggle to continue without any help at all from industry. There are differing views on this, but for me a robust ‘firewall’ between industry promotion and education is essential. People differ on how strong this needs to be, but for me any education done under a pharma banner, with pharma input into content or with access via pharma is beyond the pale. Chris rightly identifies that this line has become unhelpfully blurry, leading to the industry’s obvious interest in overdiagnosis and overtreatment to potentially influence diagnosis and practice in a worrying way. Involvement of industry in education is something we just get used to, and it’s important to challenge it as Chris has done.
Depression, ADHD and medication
The issues here are the most complex, and, I’m afraid, the worst handled. In both cases Chris makes a similar case and in both cases misleads, so I’ll combine these two.
The first part of his argument is that there has been a huge and ongoing surge in prescription
That is true to an extent, prescription has doubled for anti-depressants, but firstly that is from a very low baseline (at this point about 0.6% of the under 16 population take these meds), and secondly is not just treatment for depression- they are also use quite extensively at low dose in chronic pain.
For ADHD medication, there was a surge in the early 2000s, again from a very low base-line, but for the last 5 years of so prescription rates haven’t shifted.
So…. Kind of right. But misleading.
Secondly, Chris argues that doctors only want to prescribe meds.
This is just plain wrong. In depression, given the safety concerns, psychiatrists are in my experience desperate to avoid prescription, but often run out of other options. Likewise, in ADHD, there is no situation in which medication should be the only thing offered, even according to the NICE guidance that Chris is so critical of being ‘focused on medication’- but it happens, and the reason is the devastation of local CAMHS and other support services since 2010. This never gets mentioned across 2 hours of television. There simply isn’t enough resource even to run the evidence-based alternatives to medication that NICE suggest.
Thirdly, he argues that the drugs don’t work and are harmful
Establishing the effectiveness of psychiatric drugs is notoriously difficult. Within the field, ADHD medication methylphenidate is established as among the most effective. Chris appropriately discusses a Cochrane review that says the evidence for methylphenidate is weak, but omits the large amount of criticism from academics who felt that it discounted evidence by being too restrictive. For antidepressants he stretches things further- when a researcher says the fluoxetine has evidence of benefit on average, Chris insists on placing a question mark on it in felt tip, because it might not work in every patient. Like…. every drug ever. Chris scoots off to interview David Healy, who argues that he must be right that no antidepressants work for any child ever, because no-one has sued him- ignoring the fact that having a clinical opinion, however wrong, is not libellous. And David Healy is wrong about this.
The sections on side effects are odd.. in both cases Chris opens the medication leaflet and acts amazed at how many side effects there are and how alarming it all is, LIKE HE HAS NEVER SEEN ONE OF THESE BEFORE. For ADHD he suggests that 10% of children will experience personality change (they won’t). He talks to a woman who very sadly lost her daughter while on antidepressants, who says that if doctors knew the risks we wouldn’t prescribe these meds. Thing is, they do know the potential risks, that is why they try not to prescribe them unless they feel the benefits outstrip those risks, and spend so much time campaigning for alternatives to be available.
Finally, he claims there are effective, side-effect free alternatives that we are ignoring.
By now, you might think Chris was an evidence stickler, standing stern guard over the sanctity of the RCT… But what’s this? A whiff of pine or incense and Chris is all giddy like a schoolboy. For ADHD, having said that ‘couldn’t find anything in the UK’ (I’m guessing his copy of the NICE guidance was missing a few chapters) he turns to a mindfulness programme with ‘promising’ results. To be clear, promising means ‘not yet proven and quite possibly never proven’. But we need a story, so off he goes to group mindfulness for kids with ADHD. Now, hopefully this will be a useful approach, but so far, the better the quality of research, the worse the results for mindfulness. Even in the programme, he needed to compare the chaotic initial session with 6 children against a one-to-one session with 3 adults and one child, in order to give the impression of improvement.
In the depression story, a young person gets wilderness therapy, which Chris informs us is ‘established in the USA’, which rather suggests that it’s only our obsession with drugs that stops NHS doctors from donning Gore-tex and embracing the call of the wild, rather than a total lack of robust evidence. When the young person (who was really great, by the way) got better, the fact that she got better while taking an increased dose of her medication is glossed over, and the wilderness therapy is praised as making all the difference. Again, I would love to be able to prescribe a day in the woods, but we need evidence.
So Chris wants us to abandon medication, which has its significant problems but a much better evidence base than he is willing to give credit for, for unproven therapies that would suck resources from an already collapsing system. All the while, he is happy to ignore the many non-drug interventions which are recommended by NICE but are not available due to cuts.
The double standards are stunning, the science is junk, and the wilful ignorance of why the system is under such strain is unforgivable.
There is an interesting, thoughtful and provocative programme to be made about the collapse of the public sector in children’s mental health and public health, the consequences in terms of over-reliance on medication, and commercial interests being increasingly unopposed in education. This is not that programme, and on this evidence, I very much doubt that ‘Dr Chris’ is the right person to make it.