Some thoughts on ‘the Doctor who gave up drugs’

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.

  1. ADHD and methylphenidate
  2. Fever and calpol
  3. Cow’s milk allergy and hypoallergenic formula
  4. 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.

Conclusion

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.

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2 thoughts on “Some thoughts on ‘the Doctor who gave up drugs’

  1. “The double standards are stunning, the science is junk, and the wilful ignorance of why the system is under such strain is unforgivable.”

    The word “unforgivable” doesn’t really invite a response to this blog but nevertheless I‘ve done my best below.  
     
    Let me deal first with what I understand to be the “unforgivable” part – the fact that we didn’t mention “why the system is under such strain”: the lack of resources for Child and Adolescent Mental Health Services (CAMHS). The cuts have been appalling and perhaps this should have been in the film. Leaving it out was not a matter of “wilful ignorance” but a combination of many factors, including that (understandably) we didn’t get access to film the CAMHS teams of our patients. But the main reason is that I don’t believe funding CAMHS adequately would solve the collection of problems that the program is seeking to highlight, collectively known as “too much medicine”: over-diagnosis and over-prescription, driven in part by corporate agendas.

    There are widely acknowledged cultural and structural problems within medicine around the globe where weakly evidenced and low value pharmacotherapy is prioritised. More funding for healthcare is always welcome but will not necessarily fix this problem and in some cases may exacerbate it.

    “The double standards are stunning and the science is junk”. 
    There’s certainly weak science on both sides of the discussion and I’m sympathetic to the view that we celebrate the potential benefits of mindfulness and Wilderness Therapy with too much enthusiasm. The alternatives I chose are not well evidenced and we are clear about that. But they are less harmful and largely free from corporate influence. What the program showed clearly with both interventions was that in many ways they spectacularly failed. One single child stopped their drugs for a single day. No one watching this program could come away thinking that these therapies could or should replace drugs entirely. You correctly point out the may ways in which they fail having seen the program. Other viewers will be able to do the same. These interventions will not end the age of exploitation and were not presented as dogma. They were to illustrate the possibility of a different way of engaging with health.

    I’ll deal with some of the specific comments below.  

    Calpol
    “As long as you stick to recommended dose, all you’re doing is wasting money, you’re not causing harm”
    The Calpol advice on use is contrary to national guidelines. Many of your colleagues think this is something worth saying and this segment came from a fruitful discussion with Damian Roland, a paediatrician in Leicester. But that wasn’t the main point of this part of the program. We make the case that it is the marketing strategy of Johnson & Johnson that contributes to medicalisation of normality in early life. It’s a foot in the door for the industry rather than a huge problem itself. It leads to the widely acknowledged problem that I see in clinic and on the ward every day – too much medicine.

    Cow’s Milk Allergy and industry infomercials
    “Medical education would struggle to continue without any help at all from industry” 
    This is untrue. We have a vibrant, robust program of education in the infection department of my own hospital, UCLH, with no sponsorship at all. This is increasingly true of GP surgeries and many other hospitals. As long as we keep accepting funding from industry the incentives to find alternative strategies are minimal. I am a purist about this. The drug, device and formula industries should not fund medical education of any kind. Of course some people disagree…usually those with institutional affiliations that rely on corporate income.

    Formula Companies
    Much of what I learned and saw during filming appeared against the spirit (if not the letter) of the WHO/UNICEF guidelines. The reason I underline this is that if you found the program “unforgivable” then what language is left to describe the historical and contemporary scandals surrounding the formula industry, including the behaviour of Nestle during the 1970’s? These companies should make uneasy bedfellows for the paediatric community and the Royal College. In the words of the blog, this feels like a “stunning double standard”. 

    Depression, ADHD and medication
    Depression “Secondly, Chris argues that doctors only want to prescribe meds” 
    Could you send me the time code where you think I say this? I don’t argue at any point that “that doctors only want to prescribe meds”. After my interview with Sandeep Ranote I say this about antidepressants and I stand by this comment. 
     
    “What Dr Ranote is saying is that the reason we prescribe anti-depressants in this way to children is because it’s in the national guidelines and those guidelines are built on the best available evidence and that’s the crux of my problem with this, is that the best available evidence in my view isn’t very compelling and there are real concerns about serious side effects, so if we want to avoid doing harm, surely we should be prioritising those treatments that we don’t believe carry the same level of risk”
     
    The program fully acknowledges that Jess has had other input and therapies and she discusses this herself. I agree with everything you’ve written about NHS services – CAHMS are woefully under resourced. But that doesn’t change the fact that as a profession, we have been derelict in our use and abuse of both data and medication in psychiatry, and especially in teenage depression.

    “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.”
    The Cochrane review is indeed flawed but NICE’s own evidence review says the evidence is poor. I am simply holding NICE to their own standard. And Prof Simonoff had a fair interview where she admitted that clinical experience helps shape the guideline. This is a really lousy way of evaluating harms and benefits in any field of medicine as we both know.  
    
“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.”
    I write the question mark because of the results in the paper which provide considerable uncertainty about whether the effect is real. Prof Cipriani himself says this. 
     
    “…he suggests that 10% of children will experience personality change (they won’t)”
    The claimed benefits of the drug involve considerable personality change. This was true in some way for every single child I spoke to and it is the risk given on the information leaflet. If there is evidence to the contrary please send a reference and I will gladly read. 
     
    “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.”
    This is untrue. I do not want everyone to abandon medication. At every stage, with every condition we say that drugs have a role to play. Experts, patients and their parents make the case for the drugs very effectively. I never say or imply that I want people to abandon their drugs. I totally acknowledge that there are other interventions in the guidelines but the lived experience of the patients is that drugs are the focus. 
     
    The drugs have “a much better evidence base than he is willing to give credit for”
    * In the case of ADHD I don’t think that there is a convincing case to be made that we are confident about the benefits or the harms to children when these drugs are prescribed over many years but if you feel differently I’d be very happy to read some more papers. 
    * In the case of Sertaline is there data showing efficacy for depression in teenagers? Or rather where is something more convincing than the Cipriani metanalysis? I am sure you have read the original Sertraline paper. Efficacy of Sertraline in the Treatment of Children and Adolescents With Major Depressive Disorder. It has many of the features of a marketing trial and is written by the company who were profiting from the drug it investigates. It is weak evidence. A “lack of other options” does not justify prescribing a drug without good evidence especially where there is a real risk of serious harm. And our own medical regulator the MHRA says that this drug should not be used in children or adolescents. There is no good evidence that Sertraline is both safe and effective compared to any non-pharmacological therapy or indeed nothing at all.
     
    Conclusion
    From reading his other, largely excellent, blog posts, I suspect Max and I would be able to find some common ground. I am sure we’d both like to see higher standards of evidence for all forms of therapy to help sick kids. I think we probably agree that industrial influence over guidelines, research and education is not in the best interest of patients. 

    But rather than seeking that common ground or offering a helpful corrective to perceived errors, the blog is fault finding and dismissive. There is some valid criticism but it sits between sarcastic comments about presenting style & emphasis which feel petty when so much is at stake. This tone risks a dismissal of the messages we might agree on. As a result I believe this blog plays into the hands of Danone, Nestle, Johnson & Johnson and others, both directly and in adding to the confusion around these issues in which they thrive. 

    • Hi Chris

      Thanks for considerable effort you’ve gone to in replying in full. I’ll briefly respond.

      On the issue of tone, you certainly have a point. I am continually reminding myself to write about someone as i would speak to them in person, and there are parts of the post that fall short of that. Sorry.

      I agree that we have substantial common ground. Specifically, on industry involvement in medical education, we agree it is undesirable. I’ve run sponsorship-free events locally and nationally, and never let a rep address my team, so much so that the local reps think we don’t do ADHD. So we’re not far apart on that- i guess having seen the finances of big national conferences i can see why they feel that the trade halls are necessary… Having said that, maybe we don’t need mega conferences these days?

      So our disagreement revolves around psychotropic medication and is two fold. One, we differ in our interpretation of the evidence for efficacy. I agree that there has been some dodgy science around antidepressants but they are not without their uses in combination with other approaches. For ADHD I believe the evidence for meds in combination with other approaches is pretty sound. We can agree to disagree on this.

      Which brings us to the last point. Were you fair in your representation of the profession and balancing evidence for different approaches? Did you cover the reasons for pharmacology dominating practice (primarily cuts) fairly? You say you did, and for instance that you presented mindfulness and wilderness therapy as failures. I really don’t think that was the message that i or my colleagues received from the programmes. You representing us pushing drugs over other options on the basis of dodgy science.
      It is simply implausible and a bit insulting to say that financial restrictions are just holding us back from ever greater pharmacological excess… We have ONE parenting worker in our borough. Give me a grant and that’s the first thing I’ll spend it on. So yes, not mentioning the cuts as the real reason doctors feel backed into the situation of having no other option than meds is unfair and, if not unforgivable, very much requiring correction.

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