Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.
As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.
I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.
On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.
His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.
He might be right, but I think at least two aspects of the debate have not received as much attention as they should.
First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of ”only” a few hundred people developing schizophrenia?
Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.
When UK general practitioners, from the mid-1990′s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.
Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.
Manufacturing Depression: the Secret History of a Modern Disease had been in my “to read” pile for a few months. I was in no hurry, assuming from the title that it was a re-hash of the “marketing by pharmaceutical vested interests” arguments of David Healy and others.
But after a patient recommended it, I had a look. The author Gary Greenberg is a psychotherapist, who has episodes of severe depression himself, possibly related to his “inexhaustible penchant for dithering”. He tells a very interesting story, especially about taking part in a double-blind, placebo-controlled trial of an antidepressant. I will not reveal the ending, but do think the book should come with a bit of a health warning because the lack of black-and-white conclusions may make some readers irritated or even depressed.
Another thing I liked about Manufacturing Depression was Greenberg’s willingness to say that pharmaceutical companies and medication prescribers are not the only vested interests in the mental health “industry”. For example: “…even though I am a psychotherapist, I don’t think the only alternative is what I sell in my office one hour at a time”. And, as what Greenberg calls a “depression doctor” myself, I agree with his view that “Depression is surely an affliction, one that at least in some cases may well have a specific, although still undiscovered, brain pathology – a disease in the usual sense of that word.”.
Quotations from Manufacturing Depression: the Secret History of a Modern Disease (2010, Bloomsbury hardback): pages 365-6, 297-8, 13
Psychotherapy has been in the news recently, with the announcement that a further 400 million pounds will be made available through the so-called IAPT (Improving Access to Psychological Therapies) programme.
But although the government has stated the money is “new”, a senior IAPT adviser has been sacked, apparently for saying that is “a lie” (1). Certainly, savings are to be made elsewhere in the NHS mental health budget.
Somewhat lost in the discussion has been a shift away from the idea that IAPT is just about CBT (cognitive-behavioural therapy). In theory, IAPT has for years accepted that Interpersonal Therapy (IPT), and couples therapy, are just as valid for problems such as depression and anxiety.
At a seminar on IAPT eighteen months ago, a regional manager told me that it was proving difficult to recruit therapists for these approaches. That seems to be changing, and the British Psychoanalytic Council’s recent comments appear to be positive about psychodynamic therapies gaining significant funding alongside CBT (2).
In my view that is a good thing. Since the early 1990’s, I have been sceptical of the established NHS wisdom that psychodynamic treatments had been demonstrated to be generally inferior.
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/ .
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 BBC Trust has ruled that Panorama, in its 2007 program questioning ADHD medication, was “not fair and open minded”(1). It has ordered an “on air” apology: Panorama’s first in years (2). The headline message is that the Trust has handed out a strong reprimand.
But the Trust also says that viewers were not deliberately misled: the program makers could have “misunderstood the underlying material”. I think that families and patients affected by ADD / ADHD will find this contradictory: how can a lack of fairness and open-mindedness arise solely from a misunderstanding?
It appears even less credible when the experience of the journalist involved is taken into account: on the Panorama website Shelley Jofre is presented as a specialist in this area who has made many programs, “instrumental in forcing an overhaul of how drugs are prescribed”. In a “meet the team” video the risks “when you take on a major multinational drug company” are said to be just part of the job. The 2007 complaint pointed out that the ADHD program was a follow-up to one made in 2000, about which Panorama had, years ago, accepted a previous complaint was valid (and the “flagship” Panorama rarely concedes error). No mention is made of all this in the BBC Trust’s written reasons for its finding of a possible misunderstanding: the impression given is of a single rogue episode.
Many people who have sought diagnosis and treatment for their children with ADD / ADHD have been angry about these programs, feeling that they were portrayed not only as gullible dupes of the pharmaceutical companies, but also, by implication, as bad parents. I doubt that they will be happy with the BBC Trust’s decision to close the matter by having a quiet word with the BBC’s deputy director-general.
However, I have a degree of sympathy with the Trust’s implied view that the underlying issues are difficult to understand. As a non-academic adult psychiatrist I still find that the MTA (3) study of pre-teen children with ADHD, which generated dozens of published papers, does not reveal its meaning easily. I think I understand that the follow-up study was always likely to be difficult to interpret, given that the patients in the treatment groups were no longer encouraged to stick to their randomly assigned treatments (medication, behavioural, and “treatment as usual”). But even after the BBC Trust’s investigation I am still unclear why Professor Pelham, the psychologist who was co-author of the study, and whose views on the poor longer-term outcome of medication were ruled to have been given undue emphasis, appeared so confidently to disagree with his psychiatrist co-authors, when I understand that he had not done so in print.
Therefore I think Panorama should make available the video of its full interview with Professor Pelham, as well as other material, because it may still have relevance for how we interpret the MTA study and the follow-up. We might even see whether Panorama had the potential to make a good and genuinely interesting program, rather than the flawed one, which is regarded by many people as simply biased. If parent and patient groups want now to see a deeper enquiry or review, of all Panorama’s mental health related output, I would support that.
But I think it should be kept in mind that poor journalism and editing might be due to other causes than ordinary bias. I was unable to find any research directly bearing on precisely this context, but a comprehensive study of war reporters (4) has shown that substance misuse, depression and post-traumatic stress disorder (all problems that might even be linked to ADD / ADHD) are more common than in “ordinary domestic” journalists. Shelley Jofre’s “taking on the pharmaceutical Goliath” video might not exactly indicate the “macho values” which draw people to conflict zones, but she does talk about the “sleepless nights” that her work brings.
(2) I was unable to find mention of a previous Panorama apology on the BBC website. Incidentally, I could find no mention either of the BBC Trust’s findings on the Panorama website, which continues to state that the 2007 program “reveals that new research shows giving children drugs for ADHD works no better than doing nothing in the long-term.”.
(3) Multimodal Treatment Study of Children with ADHD: background explained in the BBC Trust report