One step forward, two steps back

I was never entirely sure about my mother’s attitude to religion, as she often criticised my father for being too dogmatic in his atheism. When she was dying, I asked her if she wanted any religious element in her funeral.

“Of course I don’t!” she snapped back, “what would I want that for?”

Then she pondered for a few seconds.

“Mind you, you could all sing ‘Abide with me’.”

“What?” I said “Like the Cup Final?”

“You ruin everything. Don’t bother.”

I was reminded of this last week when my post-holiday bonhomie was punctured by some sharp indicators of the state of public attitudes to mental illness.

Anthony Scaramucci has been sacked since I started writing this blog (!), but I still think that his brief tenure as White House Communications Director and his remarks about Reince Priebus will go down in history as the symbolic point of no return for the Trump regime. All pretence of decency and reason has been abandoned and the administration has publicly embraced degraded inchoate hatred. The use of a psychiatric term to dismiss an opponent is nothing new in politics, although it usually concerns psychopathy or narcissism rather than schizophrenia. Using a diagnosis as a vehicle for visceral loathing is more unusual. It is painful to see that this unpleasant man uses ‘paranoid schizophrenic’ as the worst insult available to him. My aunt had paranoid schizophrenia for fifty years. She was a generous woman who worked as a school secretary. She had infinitely more dignity and self-respect than Mr Scaramucci, who surely would not have found a place in public life under any previous US regime, no matter how transient.

Then, on Wednesday, there was a Panorama programme, A prescription for murder? It has proven highly contentious. It concerned James Holmes, who meticulously planned and executed a lethal armed assault on an audience in a Colorado movie theatre in 2012. The reporter strongly suggested that he acted as he did as a direct consequence of taking sertraline, an SSRI antidepressant.

The BBC trailer and tweets about the programme were truly awful. The programme content was summarised thus:

“Is it possible that a pill prescribed by your doctor can turn you into a killer?”

The actual programme was less strident. It made caveats. It was repeatedly stated that homicidal violence was a rare side effect, that antidepressants help many people and that viewers should not discontinue antidepressants without consulting with their doctor. Nonetheless, I found the programme uncomfortable viewing. I thought its approach to violence and grief was prurient and inappropriately cinematic. The programme makers’ opinion was clear: the antidepressant played a causal role in the tragedy. This was supported by two psychiatric experts, Professor David Healy and Professor Peter Tyrer. Healy has expressed similar views in TV programmes over many years. Tyrer is the former editor of the British Journal of Psychiatry and he was the 2015 recipient of the Royal College of Psychiatrists’ Lifetime Achievement Award.

Lots of psychiatrists and people on antidepressants complained that the programme was sensationalist and stigmatising. Some people felt that the programme had wiped out all the progress that has been made on stigma and mental illness in recent times. The Royal College of Psychiatrist made a prompt and well co-ordinated response, including statements about the lack of evidence for a causal link between antidepressants and violence. My Twitter feed lit up for several days with criticism of the programme and the participating psychiatrists.

What caused most upset was the suggested link between depression and serious violence. Other people felt that anti-depressants had had a substantial and positive impact on their mental health, and they objected to the medication being demonised. Many pointed out that Holmes had not been taking the drug for weeks prior to the attack and that the programme conflated side effects and withdrawal effects. Some acknowledged that there are reasons to be concerned about psychotropic drugs and their over-use, but that the programme gave a false impression about the many complexities and uncertainties. A large number of other points were made.

The programme makers did not make reference to the relevant recent literature, for example, this paper from 2015. The study found an association between antidepressants and violence in people of the same age group as James Holmes (but in no other age group) and offered a range of possible explanations. It did not show a causal relationship, but it could not exclude the possibility either. The paper, which is fairly technical, is more convincing than the anecdote and opinion that the programme relied upon.

It is hard to know the extent to which the experts’ apparent opinions were distorted by long interviews being edited down to sound bites. Healy expressed absolute certainty that the massacre would not have happened if Holmes had not taken sertraline. Peter Tyrer appeared to be saying something slightly different, but seemed to broadly agree with Healy. I do not understand how either of them came to a firm position. It is very difficult to make a robust judgement about whether a change in one factor in a complex sequence of events would make a difference to the outcome. Questions like this arise regularly in legal proceedings of various types, and they represent a trap for expert witnesses. Without God-like powers, the truth is that it is impossible to know with any certainty.

I am not an apologist for the pharmaceutical industry. I am currently researching the use of high dose opioids in chronic pain. The evidence is that such prescribing is often counter-productive and sometimes immobilising. This does not mean that opioids should never be used. The adverse effects of drugs have to be respected, and clinicians have to keep an open mind about unexpected side effects. Nonetheless, when used carefully, even problematic drugs can have substantial benefits.

I entirely sympathise with those people with a history of depression who felt personally affronted by the Panorama programme, its title and the associated publicity material. In my opinion, there was a serious misjudgement over tone. Public opinion about mental health has shifted. People with mental health problems are increasingly insistent that their point of view should be taken into account. More sensitivity is needed in media coverage of mental health. I strongly believe that all of us who are regarded as experts should be careful to avoid overstating our opinions or over-interpreting flawed evidence. We also have a duty to air well-founded concerns. The programme could have arrived at similar but less sensational conclusions if Healy and Tyrer had been more cautious in their attribution of causality in Holmes’s case.

We cannot completely reject some kind of causal link between SSRIs and aggression in the young, although I strongly suspect that if a causal relationship exists, it is much more complicated than ‘he would never have done it if he hadn’t taken the drug’. It is right to be sceptical about drug company safety data, because it is known to be flawed, and it is right to investigate rare but very worrying potential adverse effects. We have to engage with these issues. Nevertheless, we have a duty to avoid raising unnecessary anxiety and distress in people who have mental illnesses.

Those psychiatrists who feel strongly about disseminating a nuanced and realistic public understanding of mental illness and psychiatry have to develop better ways of getting complex stories across. We have to address some really difficult issues. For example, we need to get involved in a debate with those who construe mass shootings as a side effect of SSRIs rather than a consequence of the availability of weapons in the USA. Psychiatry has not been good at acknowledging the weak but important association between psychosis and violence. In glossing it over, we have denied a voice for victims and their families. If we dismiss the public’s concerns about mental illness, other groups will use the opportunity to pursue their own agenda.

I think it is perfectly proper for journalists to make programmes that have a rhetorical stand point. In my opinion, the BBC’s current Gay Britannia season is fantastic, a really moving, multifaceted account of gay history. It has a distinctive point of view. If you want the BBC to support broadcasting of that quality, you are bound to get some controversial programmes that you do not like alongside it. In any case, psychiatry needs its critics and its controversialists. So although I am unhappy about Panorama, I will not be complaining to the BBC.

To me, the most striking message from the Gay Britannia season is that things went backwards after the Sexual Offences Act 1967, and that convictions for consenting sexual acts between men increased. Things have improved a lot now, but it feels fragile. Obama was followed by Trump. Months of positive coverage about mental health was followed by a programme that distressed a lot of people. One step up, two steps back. If we are serious about changing things for people with mental illness, we cannot afford to tire. We have to rise to the challenge of informing the public about mental health in a way that is both truthful and sensitive, based on science, not on propaganda.