THE MAUDSLEY DEBATE
Charles Medawar - 16 July 2003
I was invited to take part in this debate last January. I had no idea who the
other speakers might be – only that the motion would be that, ‘This house
believes that antidepressants cause dependence.’ I strongly believe this,
but all my instincts were to decline.
Part of the problem went back to 1998, when the Maudsley-based editorin-chief of the journal, Addiction, had implored me to write an editorial
on just this theme: “Do antidepressants cause dependence?” I did so,
apparently to his satisfaction, but then the piece was spiked, following
peer review. I concluded that the Maudsley was no hotbed of academic
freedom, whatever else.
But my strongest reservations about this debate – with seven minutes per
speaker – was that such an occasion would be almost bound to muddy the
waters. The issues here come down to a wealth of evidence, and a debate
gives no opportunity to present it. The idea that anything might be solved
by trooping into a lobby, either for or against, seemed almost surreal.
At this point I telephoned Dr. David Healy for a second opinion – only to
learn that he had been asked to propose the motion. I explained my
reluctance: I can remember saying it would be a complete “a hiding to
nothing.” I still fear it – I hope I am wrong – but I eventually decided to
come, if only to offer David Healy some support. The lack of professional
support he has had over the years – not to mention all the badmouthing –
seems a disgrace.
Then, in May, the Maudsley organisers wrote formally to confirm their
invitation. They sent a flyer for the debate. The motion had been changed.
It had become, “Hooked on Happy Pills? ‘This house believes that
antidepressants cause dependence’.
Without even consulting David Healy, I immediately emailed the
organisers: “There is no way I would have accepted your invitation had
you suggested this title at the outset. It is vulgar and it trivialises the
issue, and it seems offensive to people who use antidepressants. It also
stacks the debate against the proposers - by suggesting they regard
antidepressants as "Happy Pills." Sorry, but I have no intention of
turning up on these terms.”
2
The organisers graciously apologised for any misunderstanding or
confusion. They explained: “The 'headline' 'hooked on happy pills' is
intended to be a eye-catching take on some of the media presentations to
encourage attendance at the Debate. There is no intention to cause
offence, and where people taking antidepressants have seen it they have
not felt it was offensive (although I agree it could be used in a pejorative
way depending on context and tone). It does not form part of the motion,
and we will make that clear to the audience in the advertising and on the
night.”
Later, the Maudsley agreed to drop this slant and to think again. In June,
they came up with a new headline that seemed to stack the debate even
more: “Depressed or dependent” – as if the issue was about choosing
between the two.
By this time, I felt the Maudsley might be in the grip of some significant
intellectual hygiene problem. That feeling was reinforced a few days ago,
when a journalist friend sent me a copy of the Maudsley’s press release
about this debate. This is what it says:
THE CHOICE: DEPRESSED OR DEPENDENT?
The motion: ‘This house believes that antidepressants cause dependence’
“Antidepressants, particularly the newer SSRIs, have been hailed as
wonder drugs for their safety and efficacy in treating depression.
However, recently there have been increasing suggestions that they might
not be so benign after all. The sting in the tail, it has been said, comes
when people start to come off treatment. It is then that some find they are
troubled by headaches, nausea, pins and needles, anxiety and dizziness. Is
this dependency kicking in or is it a harmless but unpleasant withdrawal
syndrome? Is this a re-run of the ‘70s when thousands of housewives and
others became addicted to benzodiazepines dished out liberally by
doctors? Are doctors and the pharmaceutical companies glossing over a
serious risk that these drugs cause dependency? Or are some refusing an
effective treatment they desperately need because of media scare stories
and distortion of the facts?
This issue has been widely publicised in the popular media, sometimes
with harrowing individual cases presented without much context or
counterbalancing scientific discussion. The Maudsley Debate brings
together some of the leading public commentators on this issue to
consider all angles.”
3
For the motion:
Against the motion:
Chair:
Dr David Healy
Mr Charles Medawar
Dr Veronica O’Keane
Professor Lewis Wolpert
Professor Robin Murray
I therefore see this debate essentially as an appeal to the press and media to propose to them that the question of dependence on antidepressants is
really quite uncertain and a finely balanced thing – and to emphasise that
the Maudsley stands for the triumph of science over prejudice and
emotion. The press release suggests that the debate will “counterbalance”
wild talk of patients feeling addicted to SSRIs – with more relevant
“scientific” evidence. Obviously, a debate like this makes it impossible to
say much about what passes for “science” in this field - but the polite gist
is that much of it is extremely poor.
Less than two years ago, GlaxoSmithKline was running TV commercials
on US nationwide TV claiming that paroxetine was “not habit-forming”.
In Britain and elsewhere, the Company went out of its way to emphasise
much the same. Until a few weeks ago, GSK emphasised in the UK
Patient Information Leaflet (PIL) for Seroxat: "Remember that you
cannot become addicted to ‘Seroxat’" …. "These tablets are not
addictive" ... Withdrawal symptoms "are not common and they are not a
sign of addiction".
GlaxoSmithKline pointed to “scientific” evidence to back up these
claims, insisting that withdrawal reactions affected only two people per
1,000 and that the symptoms were mild. They had arrived at this estimate
mainly on the basis that only seven of the 8,143 patients on their clinical
trails database had experienced withdrawal reactions. This was ridiculous,
because these trials were neither intended nor designed to investigate
withdrawal. The emptiness of this estimate is also underlined by the
omission from the GSK database of one sponsored study (Oehrberg et al,
1995) that recorded withdrawal symptoms in 19/55 patients (34.5%).
With active support from the regulators (Price et al, 1996), GSK have
been under-reporting the incidence of withdrawal reactions by something
of the order of 15,000 per cent.
At last, in June 2003, GlaxoSmithKline sweepingly revised its earlier
estimates. The new PIL admits a 25% incidence of withdrawal reactions –
even after gradual withdrawal. Incredibly, GSK also now propose that the
true incidence is actually 10% - because 15% of patients reported adverse
effects after withdrawing from placebo.
4
Are GSK and the regulators seriously asking people to accept that the
severity of withdrawal effects from placebo is identical to the active
drug? On the basis of no published evidence, so it seems.
The quality of much of the so-called “scientific” evidence bandied about
in this case has been abysmal. The perceived value of much of it has
come to depend mainly on who seeks to prove just what, and who
believes them. Thus, clinical trials sponsored by Eli Lilly and Co
(originators of Prozac) demonstrated five years ago that the risks of
withdrawal reactions with paroxetine bore no resemblance whatever to
the risks proposed by GSK.
This kind of “science” has been relied on to deny that withdrawal and
dependence cause the problems that so many users have found. The
Social Audit website is one of many where thousands of people from all
over the world provide graphic and convincing evidence of a real
dependence problem. If there were not this problem, why would The
Antidepressant Web now be getting 400,000 visitors per year?
The nub of the problem is that a significant minority of SSRI users find
themselves unable to stop these drugs because of seriously disabling
withdrawal symptoms. That problem is compounded by widespread
denial: many users are told that that they are actually experiencing not
withdrawal reactions, but the return of their original symptoms. The
reality comes closer to the experience reported in Mind Out by David
Taylor (1999), the Maudsley’s Chief Pharmacist. He found that the
official warnings and advice, “gives us almost no insight into the reality
of withdrawing from antidepressants.” His opinion was based on his own
experience and that of many others too:
“The real truth is that, for many people, antidepressant withdrawal
syndrome is neither mild nor short-lived. For six weeks or so, I
suffered symptoms which were at best disturbing and at worst
torturous. This was despite following a cautious, decremental
withdrawal schedule. Whilst I did not experience headache or
paraesthesia, the severity of other symptoms certainly made up for
it. The dizziness I felt varied from a slight wobbliness to a
frightening inability to stand up without support. For most of the
time, I could not turn my head without inducing a paralysing
nausea. Alongside this, I endured a more-or-less continuously
pounding heartbeat and a close facsimile of influenza. When all of
this subsided, I was short-tempered and moody, and remained so
for a further two weeks or more.
5
None of my conversations with others who have withdrawn from
antidepressants leads me to believe that my experience is unique or
even unusual. In fact, this severity of symptoms seems to be par for
the course with some drugs (for example paroxetine and
venlafaxine).”
Four SSRI antidepressants are among the top ten drugs that have attracted
adverse drug reaction reports (Yellow Cards) relating to withdrawal
reactions and dependence. Paroxetine (Seroxat) tops the league tables by
far – accounting for many more reports of withdrawal reactions than for
all the benzodiazepine tranquillisers combined. Bear in mind too that
many people want to withdraw from antidepressants because they cannot
stand the adverse effects: bad mood, weight gain, lack of concentration
and loss of libido are most often cited as reasons for wanting to withdraw.
Back in 1981, it was Professor Malcolm Lader and his colleagues at the
Maudsley who first demonstrated the existence of “normal dose
dependence” on benzodiazepine tranquillisers. Along with Peter Tyrer
and colleagues, Petursson and Lader identified a subtle benzodiazepine
withdrawal syndrome, one that mimicked the very symptoms for which
these drugs were prescribed. It took 20 years to establish this risk of
dependence , and the best part of another decade to do much about it.
Now, with a few twists and turns, history is repeating itself yet again.
What caused Malcolm Lader to investigate? Partly it was coming across
patients who were truly stuck on their drugs. It was also it was because he
and others were alarmed by the vast amounts of benzodiazepines used.
They were then being prescribed in the quantities that antidepressants are
used today: consumption of antidepressants has tripled in the past decade.
UK Prescriptions are now pushing 30 million/year, a level that seems
more compatible with dependence than real medical need.
Why should there be such resistance and opposition to the notion that
SSRI cause withdrawal reactions, the exact equivalent of normal dose
dependence? Partly the issue comes down simply to semantics. In a
classic example of self interest and “defensive medicine,” the authorities
radically changed the definition of “dependence” in the early 1990s. The
prime mover was the American Psychiatric Association (APA) – an
organisation hugely dependent on drug company funding – by means of
its diagnostic manual, DSM-IV. The revised definition of “dependence”
completely restructured the meaning of that term. From the mid-1990s,
“dependence” came to be formally defined in the terms you or I would
equate with frank abuse.
6
From then on, “dependence” of the kind described by Lader and Tyrer
didn’t officially exist. Withdrawal symptoms were also relabelled as,
“discontinuation” - to invite the inference that they had nothing to do with
dependence - unless there were clear signs of drug seeking behaviour too.
This was never likely, when doctors were committed to prescribing more
and more. The same applied to other hallmarks of dependence: drug
“tolerance,” for example, could never emerge as a problem so long as
doctors responded to SSRI ‘poop out’ with “dosage augmentation
strategies,” in the belief that patients would benefit when drug dosage
was kept high.
The World Health Organisation is, I believe, the only institution to have
warned of the risks we now run – but its process has been very low key.
In 1998 and again in 2002, the WHO published statements on this issue
which leave little scope for doubt that antidepressants can and do cause
dependence, just as users have been saying for many years:
"There is obviously some confusion about the concept of
dependence ... The simplest definition of drug dependence given by
WHO is 'a need for repeated doses of the drug to feel good or to
avoid feeling bad' (WHO, Lexicon of alcohol and drug terms,
1994). When the patient needs to take repeated doses of the drug to
avoid bad feelings caused by withdrawal reactions, the person is
dependent on the drug”. (WHO, 1998)
“Based on common sense, one would consider that an
uncomfortable withdrawal syndrome will increase the risk of
dependence” and “Unless studies indicate the contrary, it is highly
unlikely that a serious withdrawal syndrome will not lead to drug
dependence.”(WHO, 2002)
Opposition to the motion in this debate in the end arises for two other
main reasons. Neither of them has much to do with definitions that are
rooted in any common understanding, nor with any common sense
interpretation of the evidence, “scientific” or otherwise.
Commercial and professional self-protection and promotion have been
uppermost. To admit a mistake at this point would be as if to concede that
psychiatry and general practice are incapable of learning from past
mistakes. Exactly what happened with the barbiturates, bromides and
benzodiazepines (and others) is now happening all over again.
7
More to the point, once you accept that dependence on SSRIs is a reality,
you begin to destroy the myth that depression results from some simple
deficiency of brain serotonin. You then also have to question the alleged
long-term effectiveness of these drugs. Their reputation for lasting
effectiveness is largely based on the results of clinical trials that
discounted the existence of withdrawal reactions. In such trials, patients
were abruptly withdrawn from their drugs. Then, if they reacted badly,
this was counted as evidence not of a withdrawal syndrome, but of
“relapse” – a return of the underlying depression. From this it was
inferred that these drugs really worked. Surely, these drugs are extremely
effective for some, but also extremely unpleasant for others.
There is the further argument that, by highlighting the limitations of
antidepressants, those who mention risks may deter dangerously ill
people from getting the drugs they need. In his book, Malignant Sadness,
Professor Lewis Wolpert draws vividly and extensively on his own
experience to underline the how serious depression can be – and no one
should doubt it. Severe depression is exquisitely distressing and
potentially dangerous. However, it is important also to remember that
relatively few prescriptions for antidepressants are prescribed for
depression so severe. Today, the most unifying definition of "depression"
is that it is a condition to be treated with antidepressant drugs. The trend
in definition has been to identify more and more people as "depressed", to
extend the patient base:
"The boundaries of what constitutes depression have been
expanded relentlessly outward. Depression as a major psychiatric
illness involving bleakness of mood, self-loathing, an inability to
experience pleasure and suicidal thoughts has been familiar for
many centuries. The illness has a heavy biological component.
Depression in the vocabulary of post 1960s American psychiatry
has become tantamount to dysphoria, meaning unhappiness, in
combination with loss of appetite and difficulty sleeping". (Shorter,
1997)
Professor Shorter, a historian of medicine, has also underlined the
importance of not being over-influenced by accounts of the sometimes
extraordinarily positive effects that antidepressant can have. He has
recalled that when imipramine was first given to depressed patients in
1955, "the response was ‘absolutely incredible, so exciting’, electrifying
both the hospital staff and the Geigy scientists who had been following
this all with bated breath". Dramatic relief from bad depression may seem
astonishing, but needs to be seen in context too:
8
"The language in which Kuhn reported the transformation is
interesting, because it illustrates how resurrectionlike the recovery
from depression can be, a recovery that each new generation of
antidepressant drugs believes that it alone has achieved; witness
the resurrectionist rhetoric accompanying the introduction of the
drug Prozac." (Ibid)
The tendency to exaggerate the importance of antidepressants is strong.
For example, in Malignant Sadness (p. 166), Professor Lewis Wolpert
echoes the warning of Dr Rodrigo Muñoz, former president of the APA,
in suggesting that 10 – 15% of people suffering from depression end up
committing suicide. But if Wolpert is right in also suggesting that the
average GP sees about 500 depressed or anxious patients each year (p.
181), it would mean that every GP lost one patient a week to suicide – a
figure upwards of 30,000 per cent too high.
The question of dependence on SSRI and other antidepressants is much
too important to be in any sense resolved by voting either for or against
the motion. I believe it would be very rash simply to oppose to motion. If
you have yet to study the evidence that would persuade you to support the
motion, it would be more prudent to abstain.
I conclude by referring to a symptomatology that somehow seems
relevant to this debate. It includes, “… extreme perversion of feeling and
corresponding derangement of thought, failure of intelligence, nocturnal
hallucinations and suicidal or homicidal propensities.” These are not
SSRI withdrawal reactions; they are in fact the symptoms of masturbatory
addiction, described by Henry Maudsley, in 1874. I second this motion in
the hope of progress to come.
References are hyperlinked on the Social Audit website
Charles Medawar
Social Audit Ltd
P.O. Box 111
London NW1 8XG UK
TEL/FAX +44 (0)20 7586 7771
charles@socialaudit.org.uk
http://www.socialaudit.org.uk
9
[Anon, Selective serotonin re-uptake inhibitors and withdrawal reactions,
WHO Drug Information, 1998, 12, 3, 136-138.
WHO Expert Committee on Drug Dependence, Paper adopted at the 33rd
meeting of ECDD, Geneva, 27 September 2002.