Last month’s radio programme about lobotomy (1) is interesting because it slightly departs from the usual historical scripts, which are: evil psychiatrists used lobotomy as a destructive form of social control, or well-meaning but weak ones rubber-stamped the decisions of others, such as Nurse Ratched in One Flew Over the Cuckoo’s Nest.
It emphasises that the inventor, and two of the main promoters of lobotomy were in fact not psychiatrists. Politician and neurologist Egas Moniz started the ball rolling. Then, American neurologist Walter Freeman, and the British surgeon Sir Wylie McKissock, both continued to do thousands of operations despite evidence for uncertain therapeutic results.
Historical radio and TV programmes about the bad aspects of the old asylum system (which I don’t advocate returning to, but will say it was always underfunded) are often a means, I think, of deflecting attention from current NHS mental health failings. Other occasional broadcasts about the mental health systems of second- or third-world countries generally have the same function.
At least this one is a little different. However, it seems to me that there is a clear parallel between lobotomy and another kind of invasive operation for a serious behavioural (and often psychiatric) disorder today.
Although obesity surgeons are not household names (yet), there has never been a proper trial of gastric banding or the more serious procedure of partial gastric reduction, despite thousands of operations being done annually (2). The rush to surgery is delaying the development of new non-surgical treatments, and the application of at least one recently developed and partially tested treatment (for obesity-linked ADD / ADHD).
The programme-maker did not draw attention to this obvious parallel. Was he or his boss warned off by England’s Department of Health, which for much of the last decade had surgeons both as chief medical officer and as a health minister? Or was it (perhaps more likely) BBC self-censorship?
BBC journalists don’t themselves seem to believe, any more, that the “licence fee” protects their independence because it is supposedly “not a tax”. But they continue to resist the suggestion that their work should be subject to the Freedom of Information Act.
So ordinary patients who have experienced poor results, infections or other complications from bariatric surgery, may never be able to discover the extent of any such BBC collusion. The same goes for relatives who, following one of the thankfully few deaths directly caused by bariatric surgery, may take a retrospective interest in how this surgical descendant of lobotomy was promoted.
(2) See my previous pieces on obesity: http://drnmblog.wordpress.com/category/obesity/
Drafted 2nd December; final version 8th December
When the comedian Rory Bremner talked about his possible ADHD in May this year, it attracted a lot of media attention. But I was uneasy, feeling that the half-hour BBC radio programme appeared to risk trivialising his problems: nearly forgetting his lines on stage, losing things, being a bit disorganised. Hardly a definite case for treatment in someone who is, after all, a very succesful entertainer.
There was no mention of his own past history of anxiety and depression (2), conditions which are well-documented as being linked to ADD / ADHD. In my experience, ADD / ADHD is often a direct cause of anxiety and depression, not least because disorganisation and impulsivity lead to negative life events.
A couple of weeks ago the mental health charity SANE launched its “Black Dog” campaign, to re-raise awareness of depression (3). Despite Bremner being a prominent part of SANE’s campaign, it attracted nowhere near the same media coverage nationally.
I have no idea whether Rory Bremner’s past problems with anxiety and depression had any link with ADHD. But it does seem worrying that the May BBC radio programme did not explore the possible harmful consequences of undertreatment.
*See The Gift of ADHD?, below at: http://drnmblog.wordpress.com/2011/03/20/the-gift-of-adhd/
Drafted by 5th August 2011, published at DrNMblog.wordpress.com on 6th October 2011
Over the last three weeks the BMJ has published several articles by the investigative journalist Brian Deer, and an editorial co-written by a leading GMC member, alleging that ex-Doctor Andrew Wakefield’s research linking MMR to autism was a fraud.
Brian Deer, The Sunday Times and Channel Four’s Dispatches should be congratulated. The current BMJ editor is right to say that medicine needs more investigative journalism, and to highlight the need for wider vaccination against measles.
But several problems remain. The neutral observer might well ask how the “good” investigative journalism of Mr Deer is to be reliably distinguished from the “bad” of the Daily Mail, the Daily Telegraph and Private Eye (1). Is it really just the detail, the lengths to which Mr Deer went? I am not convinced that if the Mail’s Melanie Phillips (say) had spent the same amount of time on the story, she would have ended up believing Andrew Wakefield to have been fraudulent, or even deliberately dishonest.
Mr Deer himself seems to recognise the limits of his three BMJ pieces. In a Press Gazette interview last year he indicated that there is no real distinction between scientific journals, newspapers and magazines. He stated in a Guardian Blog (12th January 2011) that the BMJ was part of an “insidious cartel”. What difference does it make, then, that his first BMJ piece was “peer reviewed”, anonymously as usual? Perhaps it would have been more consistent for him to decline such a closed process.
The Lancet’s Richard Horton is alleged to have acted from largely “medical establishment” motives. But in my view there are two significant flaws in the Deer/BMJ account, across the several pieces and editorials. First, it distorts and minimises the history of the “autistic enterocolitis” construct, which developed from a decade or more of speculative but “peer reviewed” research, and not merelyWakefield’s undisclosed legal action.
Second, it ignores the wider context in which the worldwide anti-vaccinationist movement has grown. The British Medical Journal and the Lancet have both played an important role in the current debate, following Vioxx and other cases, about “industry” conflicts of interest and the right balances between openness, promotional claims, and business interests.
However, the BMJ has gone much further, even at the height of the MMR scare in the UK, in promoting scepticism about the “inappropriate domination of the Western view of mental health”, a process in which “doctors and the pharmaceutical industry” irresponsibly push both “Western cultural ideas” and “a rapid growth in the numbers of children diagnosed with conditions such as attention deficit hyperactivity disorder and autism” (Timimi, BMJ, 2005).
Two days after Brian Deer’s second article, a Blog piece entitled “How to stop the medical arms race” by a former BMJ editor revealingly set out the default position of the journal (Smith, BMJ, 13th January 2011): select evidence of “technology” and “doctors” leading to worse outcomes, not better. That Richard Smith’s Blog piece was typically urbane and self-deprecating might suggest that here, rather than in the Lancet, lie the real views of the “medical establishment”.
The BMJ has also published many opinion pieces by the “No Free Lunch” campaigner Des Spence which strongly criticise Western medicine. For example: “big pharma use[s] political lobbying to pervert the course of medical justice” (11th March 2009), and “A medicated childhood is blunt, defies reason, and is just bad medicine.” (21st July 2010).
Dr Spence has stated that because of the need to “protect the consumerist patient from themselves”, he and other GP’s suggest “complementary treatment, and even placebos” (4th February 2009). This seems to be a lesser-evil approach, but I have been unable to find any acknowledgement that such GP behaviour, rather than patients’ “health neurosis” (2), could cause the rejection of MMR vaccination (29th July 2009).
Taken together, when some parents, journalists and politicians read views like this, in the light of their own experience of the indifference shown by the “medical establishment” to neurodevelopmental disorders (3), it is not very surprising that they prefer a different version of events: Andrew Wakefield’s continued fight against Western medicine’s vaccine industry, which scored a temporary victory during the fitness to practise (FTP) panel’s 45 days of deliberating in secret (to use Brian Deer’s preferred term, rather than the GMC’s euphemistic in camera). The Wakefield FTP hearing transcript is still not publicly available on the GMC website (4), despite the BMJ’s declaration two weeks ago that it had been published.
Finally, the eminent “evidence-based medicine” expert Professor Trisha Greenhalgh appears to risk inflaming the situation further by repeating a comparison of the MMR sceptics with “flat-earthers” (rapid response, 18th January). This perhaps shows how remote the BMJ is perceived to be from the concerns of ordinary patients, and the “front-line” staff who do not have the luxury of engaging with pro-MMR families only.
If medical journals are really just newspapers with mystique, might it follow that a way out would be for medicine to become an honest trade rather than a dodgy “profession”? No doubt the size of the financial transaction between the BMJ and Brian Deer was small; and it remains open whether the journal’s new policy of modestly remunerating “good” investigative journalism at the expense of “bad”, will have the desired result in respect of the larger dragons of commercialised medicine, which the BMJ appears to see as its mission to slay.
A version of this piece was submitted as a “rapid response” to the last of Brian Deer’s articles, on the day of it’s publication (18th January). Four days later, no “rapid responses” had been published, which will only add to the suspicion that the BMJ is attempting to rig the debate. [The BMJ published an edited version of my “rapid response” in the 12th February print edition:
http://www.bmj.com/content/342/bmj.d809.extract, and a longer online version on 4th February:
All the BMJ quotations can be searched for at http://www.bmj.com/search.dtl .
(1) I attribute this simplistic good/bad dichotomy to the BMJ. It is not my own view, as it should be clear from the rest of this piece that I consider the BMJ itself to have partly caused what is now denounced. The current Private Eye health editor, Phil Hammond, has said that the magazine should not have reported on the Wakefield/MMR issue in the way that it did.
(2) [“Health neurosis” is a quotation from Dr Spence’s 28th July 2009 article: note added 28th February.] This could be called “blaming the victim”, although Des Spence would perhaps argue that the “neurotic”MMR-sceptic is primarily the victim of Western medicine, rather than some GPs’ well-meant promotion of homeopathy and other alternatives.
(3) The prominent vaccine specialist Paul Offit acknowledges this, in the latest introduction (readable with Amazon’s “look inside”) to his book Autism’s False Prophet’s. [Notes 2 and 3 were incorrectly transposed in original: corrected 28th February]
(4) Searching for “Wakefield transcript” or even just “Wakefield”, on http://www.gmc-uk.org/ .
England have today won the Ashes in Australia for the first time since 1986. The media have contrasted the travelling England supporters’ cheerful optimism through the last two dozen years, with the fair-weather Australians, who deserted the stands as this Tour played out.
Like the “Tartan Army” who support the Scotland football team, many of England’s cricket supporters abroad are said to drink heavily and yet stay good-humoured. This “Barmy Army” has attracted the attention of academic sociologists, who suggest that they have created “a new form of English national identity” (1).
“Barmy” of course means “mad” or “insane”. As far as I know, no charity or professional group has censured the “Barmy Army” for the name they have chosen for themselves. To do so would itself be seen as crazed political correctness, which shows the importance of context for language like this (2).
English, (mostly) male sports fans who have been drinking: the more usual image is of football supporters facing off against baton-wielding European riot police (3). Both the Barmy and Tartan Armies show that it is not alcohol itself that inevitably leads to public disorder (4): for that to happen there has to be an advance expectation of hostility and violence. Perhaps the message in the “Barmy” name is that expectations can be changed.
So if toasting England’s Ashes victory tonight, pay attention to context and expectations; before downing those units of fizzy chardonnay, Aussie or otherwise.
(1) Parry M, Malcolm D (2004) England’s Barmy Army: Commercialization, Masculinity and Nationalism. International Review for the Sociology of Sport. March 75-94. I have only read the abstract, at: http://irs.sagepub.com/content/39/1/75.abstract
(2) See ‘ ”Nutters”, “Fruitcakes” and “Loonies” ‘, 30th April 2010: http://drnmblog.wordpress.com/2010/04/30/nutters-fruitcakes-and-loonies/
(3) Documented in Bill Buford (1990) Among the Thugs
(4) A recent article in the Bulletin of the World Health Organisation seems rather confused. Despite the title – Governments confront drunken violence –implying a strong causative role for alcohol, the experts quoted appear to differ widely about social factors. Just one example: France is stated to have a growing problem, but the overall consumption of alcohol in France has continuously fallen in recent decades.
“…the scan which will enable doctors to diagnose autism more cheaply and quickly. The rapid test has already proven more than 90 per cent accurate in adults…”
“What the computer can do very quickly is to see that a patient has autism…even though their brain, to the naked eye, looks very normal.”
These bold statements appear on the website of the Maudsley Hospital’s national specialist services department (1). They appear to have been recycled from press releases and media interviews back in August, after publication of a study which looked at computerised pattern recognition of MRI brain scans, in adults with autism.
At the time, the “90% accurate” claim, and the suggestion that the scan could replace current clinically-based diagnoses, was heavily criticised by the head of the authoritative Oxford-based Centre for Evidence Based Medicine (2). A very different “5% accurate” was Dr Carl Heneghan’s view.
The key issue is that because the scan gives a “false positive” result in 20% of people without autism, it is unlikely ever to be useful, on its own, for diagnosis. If the prevalence of autism in the whole adult population is around 1%, then the “false positive rate” of the test would probably have to be at most 0.1% (3).
I wish the researchers (based at the Maudsley’s academic partner, the Institute of Psychiatry) the best of luck in getting their false positive rate down from 20% to this extremely low figure. I won’t be holding my breath.
What may be more feasible, and is implied by some of the comment back in August, is to combine the scan with a shorter (and cheaper) clinical assessment than the one which the Maudsley uses currently.
But I think patient groups, particularly the large and influential National Autistic Society (NAS), would want to see proper testing of such an approach.
Following the criticisms in August, the lead researcher responded: “we have clearly stated that we are not yet ready to make our approach available in the NHS just yet.” (2) (4).
So I was surprised to see the Maudsley website piece, dated November 4th, say “Adults who are interested in being scanned will need to ask their GP, consultant or health professional for a referral letter to the Behavioural Genetics Clinic. Privately funded assessments or scans are not available.” (1). There is no mention of any research showing the “Autism Scan” to have been improved.
Next week I am meeting with a board member (7) of DANDA (Developmental Adult Neuro-Diversity Association) (5), and will suggest that patient groups might want to clarify these apparently inconsistent statements (6) before recommending the “Autism Scan” to their members and supporters.
(3) That would mean about 1 false positive diagnosis in 1000 people, which I think would be the most any ordinary clinician would allow. To demonstrate such a small false positive rate would also require a much larger study than the one reported. Because the “Autism Scan” is said to be “90% Sensitive”, 9 people in 1000 with autism will be diagnosed correctly, while 1 person with autism will be “missed”.
Dr Heneghan does not mention the issue of the lack of so-called “confidence intervals” in interpreting the false-positive and false-negative figures from such a small study (20 patients with autism, and 20 controls without), but this seems important to me, especially for a test being offered to the NHS.
(4) Two “yet”’s in the original.
(5) The study also looked at whether the Scan could distinguish between autism and ADHD. It could, but even less well than between autism and no-autism. DANDA is concerned with the overlaps between autism, ADHD, dyslexia and dyspraxia, so I think this will be of interest to them.
(6) In addition to the other points, the 4th November piece (quoted in my first line) states “more than 90 per cent accurate”, but the abstract of the research paper (link from (1)) has “sensitivity…of up to 90%” [my italics]
(7) Changed from “the acting head” on 3rd December. My thanks to Erika Musselwhite of DANDA for pointing out that noone has yet taken over the national coordinator role which Mary Colley so energetically pursued until her recent much-regretted death.
A boy who had to leave a ”big sporty” independent school because of ADHD, was so good at rugby that he helped his team to win a match by scoring a try on his last day, according to an account written anonymously by his mother in last Friday’s Daily Telegraph (1).
Although I currently see teenagers only from eighteen years of age, a couple of years ago I saw some children in their mid-teens at independent schools, because of my association with Professor Peter Hill. Many of my adult patients have had non-state education.
It is clear that some schools in the private sector are more accepting of ADD / ADHD and other developmental problems than others. It seems surprising, though, that the school in the Telegraph article, which in 2008 apparently claimed to welcome children with special educational needs, was not more helpful in guiding the parents towards proper diagnosis and treatment at an earlier stage.
The story had a happy ending, with a good response to ADHD medication, and “…a course of therapy with a psychologist from our local authority’s Child and Adolescent Mental Health Service.” Enabling the boy’s settling in to another independent school.
The original school may well have changed its attitudes and procedures by now. But other parents in a similar situation may want to consider whether obtaining early external assessment and perhaps intervention can save the relationship with a school. It might have been the fear of the anonymous parents in the Telegraph article that the school would be antagonised, but that rarely seems to happen in practice.
A little more openness and transparency about the “not fair and open minded” 2007 Panorama ADHD programme…
…has been achieved by reluctantly becoming a complainant to the BBC myself.
On 1st October the Panorama archive page entry for What next for Craig was changed (2), after I pointed out that it still showed the flawed programme summary (“…new research shows how giving children drugs for ADHD works no better than doing nothing in the long-term.”) (3), eight months on from the BBC Trust ruling. Also, the programme title now clicks through to the Trust ruling itself, rather than “page not found”.
On a number of other points I will be consulting with AADD-UK and DANDA, who supported my initial (March 2010) enquiry and subsequent complaint, before taking the issue further to the BBC’s head of News and Current Affairs.
The primary aim is to obtain unedited interviews with professionals and academics from the 2000 and 2007 programmes, which could be very useful for our interpretation of US-based research into ADD / ADHD. Panorama’s current editor claimed that this would not be possible due to “BBC policy”. But this was clearly inaccurate given the increasingly common media practice of releasing unedited material, and the subsequent complaint has resulted in an acknowledgement that BBC editors have wide discretion to make such unedited interviews available.
In due course I intend to place all my correspondence with the BBC on this website.
None of this would be possible without the immense persistence of the original complainant (not myself) to the BBC, who finally obtained the “not fair and open minded” ruling and the rare on-air apology. It has been suggested that this original complainant was a “front” for the pharmaceutical industry, but I can confirm that this is not accurate.
The issue will be pursued with an emphasis on fairness to all concerned.
(1) See DrNMblog pieces on 5thMarch, 19th March, 28th May. Tags: Panorama, BBC
(3) Panorama archive page before 1st October: Panorama 2007 ADHD: archive to 1st October 2010
The history of psychiatry is littered with over-hyped claims for biological causes and treatments. Sceptical clinicians and the public often over-react by failing to acknowledge and put into practice more modest, but genuine, biomedical advances.
Now it seems to be happening again with ADD / ADHD. A large study appears to have shown that about one in seven children with ADHD have a genetic variant, while only one in fourteen apparently normal children have it.
But the senior author of the study has been widely quoted as stating “Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children.” This appears to be Professor Thapar’s real view, because the statement came from the press release (1), rather than an interview with a journalist trying to get a striking soundbite.
“What about the six out of seven who don’t have this genetic variant, and how come you can have the variant but not have ADHD?” has been the response, quite rightly, from journalists and commentators.
Whether poor use of words, or poor use of ordinary logic, either way Professor Thapar’s error must put some doubt over the study itself, although I would be surprised if other research centres fail to confirm the main findings over the next few years.
For me, another missed opportunity was the failure to highlight that these ADHD-linked variants were also strongly linked to learning disability (low IQ). Both children and adults with learning disability have poor access to diagnosis and treatment of psychiatric disorders, including ADD / ADHD, in theUK.
(1) See http://medicine.cf.ac.uk/en/news/first-genetic-link-adhd-revealed/, although I am not sure if this webpage from Cardiff University is identical to the Lancet press release, which appears to be closed to the public
This post is almost identical to my online comment (number 195) on the Blog of the BBC medical correspondent Fergus Walsh:
Writing in The Huffington Post, an American novelist has stated that football* will never catch on in the United States, because it is too boring to watch (1). “American sports fans…crave the excitement presented by the chance of a score on every play.”
One of his European readers responds by suggesting that high rates of ADD / ADHD might account for this drive towards instant gratification. But is it true, anyway, that people in the United States generally lack restraint, live more “in the moment”, thoughtlessly follow their impulses and desires?
If so, the US would, for example, have higher rates of alcohol and substance misuse compared with other cultures. Recent large-scale studies do not confirm this (2). The best physical indicator of alcoholism, cirrhosis of the liver, is still much more common in supposedly non-impulsive France (3). Moreover, despite a steady fall in the real price of alcohol, and relentless promotion (not least within sporting events) both overall alcohol use and misuse have declined in the US over recent decades (4).
The sport of the aspiring American businessman is golf, and US television ratings for major tournaments indicate an abundance of patience to follow such events over four days, far in excess of a ninety minute football game.
This Sunday the world cup climaxes. If the USA team had gone even further than the last sixteen (drawing against England), if they were playing against the current European champions, Spain, in the final, would football have become more of a credible spectator sport for Americans? I think so.
* This blog is primarily for UK readers, so “football” means “association football”. Note added 10th October 2011
(2) McBride et al (2009): Further evidence of differences in substance use and dependence between Australia and the United States. Drug and Alcohol Dependence
(3) World Health Organisation (2004 figures – published 2009)
(4) Zhang et al (2008): Secular Trends in Alcohol Consumption over 50 Years: The Framingham Study. The American Journal of Medicine. This study found that “heavy” use had declined, but not alcohol dependence.
An article in Education Guardian this month (1) received some interesting online responses, two of which pointed out that Ritalin (methylphenidate) has been used clinically in ADD / ADHD for fifty years. There did not seem to be overwhelming agreement with The Guardian’s scourge of health misinformation Ben Goldacre, who has stated “Big Pharma is evil” (2).
There was, however, little picking up on the valid concern expressed in Are drugs the solution to the problem of ADHD among young people? that NHS specialists who diagnose and prescribe may be forced to cut corners in their assessments and monitoring (3). Just one parent with an ADD child, and a mixed experience of services, posted on this: “The best treatment involved regular visits to the psychologist (every 6 -8 weeks) with ALL the family so we could all work out what was working and what was not.”
Unlike the BBC, The Guardian is free to be opinionated. Even so, it is disappointing that all the paper’s print and online articles mentioning ADD / ADHD continue to avoid reference to Panorama’s two programmes on this topic, both of which had complaints upheld against them. The more recent one was found to be “unfair and not openminded”, resulting in a rare on-air apology (4). Given the BBC’s massive online and broadcasting influence, and Panorama’s “flagship” status, this seems to be essential context for understanding public and professional attitudes to ADD / ADHD.
I was also concerned that an academic educationalist who does not “acknowledge that ADHD is even a medical condition” because “You can’t do a blood test to check whether you’ve got ADHD” appeared to go unchallenged. Epilepsy, bipolar disorder, migraine, schizophrenia and depression all lack definitive physical tests, and may improve with psychological treatments, but does that mean no one should ever take medication for these conditions?
As the online responses to this article showed, Guardian readers should not be stereotyped as simply following the line that mental and behavioural disorders are, in general, just “marketing” tools for pharmaceutical companies.
(2) Bad Science (2009, paperback edition) page 201. From the context, Goldacre appears to be half-joking.
(3) See “Critical Psychiatry”, 2nd April 2010: http://drnmblog.wordpress.com/2010/04/02/%e2%80%9ccritical-psychiatry%e2%80%9d/
(4) See my postings on Panorama, 5th and 19th March, below