That drug companies play fast and loose with study data is hardly news. It’s a widely-acknowledged problem that has been highlighted particularly with antidepressant trials where the advantage over placebo is often equivocal. Not before time, someone has decided to draw a line: “Deception through concealment is no trivial offence”, says the director of IQWiG – the German version of NICE – as he accuses Pfizer of concealing data about the antidepressant, reboxetine.

IQWiG (The Institute for Quality and Efficiency in Health Care) has ruled that reboxetine has no proof of benefit. They report that the drug has been tested in at least 16 trials but in 9 of them key information is not reported so they are unable to evaluate the effect of the antidepressant on 3000 of the 4600 patients enrolled. What are the implications of their ruling? The watchdog provides an assessment that is used to inform which medical treatments can be reimbursed through the public health insurance system in Germany – Europe’s largest market for drugs.

A rather sniffy spokesman for Pfizer told the BMJ that IQWiG is not a ‘regulatory authority’ but a ‘private institute’ and that there was no obligation to provide them with information. This seems at odds with Pfizer’s own policy on disclosure: “in all cases study results are reported by Pfizer in an objective, accurate, balanced and complete manner and are reported regardless of the outcome of the study or the country in which the study was conducted.”

Reboxetine itself has had a bit of a mauling of late. The Lancet’s recent comparative meta-analysis of 12 newer antidepressants put reboxetine at the bottom of the pile both in terms of efficacy and tolerability. It’s also not available in the US as the FDA turned down the application for a license for reasons which are still unclear. Paradoxically, if this license had been granted current US legislation would have required full disclosure of all the trial data. IQWiG is now calling for a similar European Union-wide legal obligation to publish all trial results as clearly self-regulation by the industry is not working. Corrado Barbui, writing in EBMH, made the same point back in 2007. Isn’t it time to get on with it?

After a bloodbath at the ballot box, the knives are out for the party leader. Media commentary is awash with Shakespearean allusions, although a more apt reference would be ‘The Tragical Comedy of Punch & Judy’. As past slights and feuds come back to haunt Mr Brown here is a timely article on the psychology of retribution in the journal Monitor on Psychology. It appears that revenge may not be as sweet as we think.

“Explaining madness is the most limiting and generally least convincing thing a movie can do.” That was the view of the critic Pauline Kael, and despite mental illness and its treatment remaining an ever-popular source for film-makers it is an opinion that I think still holds true. Psycho-killers, maniacs, hysterics, and the ubiquitous manipulative, deviant psychiatrist: stereotypes and clichés abound.

I recently watched Clint Eastwood’s film Changeling, a drama set in Depression-era Los Angeles ostensibly based on real events involving a missing child. A major theme is the role of psychiatry as a means for the social control of women. A subject worthy of exploration certainly, but we could do without the almost inevitable addition of the ‘Cuckoo’s Nest’ scenes: the barbaric use of involuntary electroconvulsive therapy. ECT certainly makes for melodramatic viewing, but it was introduced as a treatment in 1936 and wasn’t being used in 1928 when the film is set.

Last month saw the US release of The Soloist, a film ‘based’ on a book telling the story of Nathaniel Ayers, a musician with schizophrenia. I can’t comment as it hasn’t reached the UK, but typically it has received contrasting reviews for its depiction of psychosis: a sentimental cheapening, or a triumph. Your views would be welcome on this or other films that you believe provide a persuasive and truthful account of living with mental illness.

Coincidentally one of The Soloist’s lead characters is played by Robert Downey Jr. – an actor who provoked outrage in the scabrous Tropic Thunder for satirizing Hollywood’s ham-fisted approach to mental illness and learning disabilities. If you want to win an Oscar: “Never go full retard. You don’t buy that? Ask Sean Penn, 2001, “I Am Sam.” Remember? Went full retard, went home empty handed…”

Offensive? Certainly, but as honest an appraisal of the portrayal of mental disorder in film as you’ll find anywhere.

Last week NHS Yorkshire and Humber released the findings of an external investigation into the care and treatment of Benjamin Holiday. You can find the report here. In January 2005 Holiday, a young man with schizophrenia, killed a pregnant woman, Tina Stevenson, stabbing her in the street close to her home. He was under the care of a community mental health team and living at home with his mother. Having no recollection of the attack he pleaded guilty to manslaughter with diminished responsibility and has been detained indefinitely in a special hospital.

Department of Health guidelines (shouldn’t that be directives?) call for a series of reviews when a homicide has been committed by a person who has been in contact with mental health services:
1) A fast-track (72 hours) investigation to identify any necessary immediate action
2) An internal mental health trust investigation (within 3 months)
3) And finally, an independent investigation commissioned by the Strategic Health Authority.

The reasons for an external investigation are obvious: lessons must be learned to prevent such events happening again. But do they work? They certainly provide a revealing insight into the day to day care of someone living with a severe mental illness, affording a degree of transparency for relatives and carers that is rarely available elsewhere. And outcomes? There have been at least 400 homicide inquiries in the last 15 years yet the rates of homicide by people with mental disorder remains unchanged: 30-50 from 800 homicides annually, with fewer than 10 committed by people with a psychotic illness (the remainder largely related to personality disorder and drug misuse). The recommendations have become familiar too: improved risk assessment, better communication and better record-keeping. Another report isn’t needed to tell us that. The Holiday Inquiry illustrates their inefficiency. Tina Stevenson was killed in 2005; the inquiry reports four years later in which time things have changed. We have a new Mental Health Act, community treatment orders, crisis resolution teams and I’m sure that like elsewhere, services in Hull have been completely reorganised. The authors acknowledge that much of what they say was reported in 2006 by the mental health trust’s internal review.

Much has been made of bringing an end to the ‘blame culture’ in the NHS which encourages staff to cover up errors for fear of retribution. The new focus is on systematic factors that allow such errors to be made. It is human nature, however, to search for a scapegoat and in this inquiry: “…if we are allowed to indulge in one piece of viewing this investigation through a ‘retrospective-scope’ we would conclude this was a missed opportunity to possibly break into the cycle”. What they are referring to here is the decision by a social worker not to complete an application to detain Holiday under Section 3 of the Mental Health Act two months before the homicide. At the time however, he was agreeing to an informal admission, and following his discharge one month later he was seen by a nurse on two occasions and given his depot antipsychotic injection. It is just as plausible that by detaining him at that time he may have become less cooperative with treatment and disengaged completely - a classic example of hindsight bias.

Of course these points have been made before. In 1999 the DoH’s Safer Services report recommended that homicide inquiries be scrapped but they keep on coming. Clearly they fulfil a social need. The Department of Health guidelines state that mental health services must ‘be seen to investigate’ any serious incident and though not explicit, the allaying of the publics’ anxiety about the mentally ill is key. We used to have asylums to contain the mad, but now we have community care – an idea that now attracts as much vilification as political correctness. The fear of mental illness is as potent as ever and homicide inquiries serve to remind us that whilst they may live among us, they remain alien and dangerous - as illustrated by headlines such as this: Crazed Killers - trust’s failings exposed.

If they are not mad when they go into these cursed Houses, they are soon made so by the barbarous Usage they there suffer.
Daniel Defoe, Augusta Triumphans (1728)

“Civil lunatics are people that the society doesn’t want to be roaming around causing problems, unfortunately they are dumped in our prisons”, comments the controller of Enugu Prison in Nigeria. In this article from the BBC Andrew Walker visits a prison where people with mental illness may be detained indeterminately by court order, often on spurious grounds. Given the level of overcrowding in Nigerian jails, the prison service itself is keen for ‘civil lunatics’ to be diverted elsewhere – sounds familiar?

Prison Rehabilitation and Welfare Action (PRAWA) is a human rights organisation lobbying for the discharge of the mentally ill from prisons. Since 2007 they have managed to get 54 people released from Enugu Prison, clearly an arduous task. And what happens in the community? You can read more about mental health care in Nigeria here.

Interesting fact: there are more Nigerians working as psychiatrists in the UK alone than in the whole of Nigeria.

If you were at a loss for something to do in London this weekend, and the marathon didn’t sound appealing, you could have opted to ‘increase your heterosexual potential’ by listening to psychologist Joseph Nicolosi speak at the 2009 Sex and the City conference.

Then again, maybe not. This was no ordinary conference on sexual health. Organised by Anglican Mainstream, a Christian organisation “committed to the traditional biblical teaching on marriage, the family and human sexuality”, Sex and the City was billed as a Judaeo-Christian conference for all and featured Arthur Goldberg, author of Light in the Closet: Torah, Homosexuality, and the Power to Change. The keynote speaker, however, was Dr Nicolosi of the US National Association for the Research and Therapy of Homosexuality who apparently has “a proven track record over almost 30 years in helping people exit the gay world”. Despite the opposition of both the American Psychiatric and Psychological Associations to psychiatric treatment or psychotherapy designed to change a person’s sexual orientation, Nicolosi considers homosexuality to be a consequence of a ‘gender-identity deficit’ and as such advocates a treatment, reparative therapy, which he claims provides a complete cure for 75% of his patients. I’d like to see the supporting evidence for that.

You can hear Dr Nicolosi on the benefits of so-called reparative therapy here; and this salon.com article gives a view from a therapist’s couch. You might just dismiss all of this as half-baked ideology coming from a screwball fringe but last month Annie Bartlett and colleagues published their survey of UK mental health professionals finding that 1 in 6 responders had attempted to help lesbian, gay or bisexual people become heterosexual.

Unfortunately, even if you really were interested in spending your weekend listening to Dr Nicolosi “redeeming sex today” you would have to uncover the conference’s secret London location. Such discretion seems unnecessary, given the popular appeal of his last London meeting: Time for Truth - Is Gay Real?

With free market capitalism seemingly spinning off into oblivion, despite the best efforts of our Supreme Leader and his G20 disciples, the benefits of globalisation for the world economy are looking a little shaky at the moment. Whilst it has brought an unprecedented increase in prosperity for some, for others low wages and an economy underpinned by massive debt mean that the world seems a more unequal place than ever before. These inequalities are of course not just international but intranational: countries are made up of classes.

In 2004 Michael Marmot charted the impact of inequality on health in The Status Syndrome. This month his text is joined on the shelf by The Spirit Level (Richard Wilkinson and Kate Pickett). Both books marshal an array of epidemiological studies to present a robust bottom line: there is a strong correlation between a country’s level of economic inequality and its social and environmental problems. What’s more, it isn’t just the poorest in the most unequal societies that suffer but the richest too. So according to Wilkinson, “countries such as the US, the UK and Portugal, where the top 20% earn seven, eight or nine times more than the lowest 20%, scored noticeably higher on all social problems at every level of society than in countries such as Sweden and Japan, where the differential is only two or three times higher at the top.” And those social problems range from obesity to big prison populations, from teenage pregnancy rates to, of course, mental illness.

That an unequal society leads to more mental distress may seem self-evident but a study recently published by the World Health Organisation – Mental health, resilience and inequalities – amasses a broad range of evidence to show that mental health problems are not only more pronounced in unequal societies, but that mental health is also key to understanding the impact of inequality on a range of other health outcomes. Dr Lynne Friedli, the report’s author, maintains that the chronic stress of struggling with material disadvantage is intensified by doing so in more unequal societies. In turn chronic stress has a deleterious effect on the neuroendocrine, cardiovascular and immune systems increasing the risk of disorders such as coronary heart disease and metabolic syndrome. Maybe so, although the strength of the evidence is contestable. But what’s to be done? Dr Friedli’s wish list seems rather optimistic:

• social, cultural and economic conditions that support family and community life
• education that equips children to flourish both economically and emotionally
• employment opportunities and workplace pay and conditions that promote and protect mental health
• partnerships between health and other sectors to address social and economic problems that are a catalyst for psychological distress
• reducing policy and environmental barriers to social contact

This sounds too much like ‘motherhood and apple pie’ to me, although a strident call for wealth redistribution would probably be asking a lot of WHO. Of course, the UK government would claim that they have made considerable progress in all of these areas over the last decade. If that is the case, why is there a need to convene a new National Equality Panel to show how your chances in life are influenced by, among other things, ‘how much money you earn’? We are also awaiting another review of Health Inequalities in England to show us the way.

Gordon Brown is busy trumpeting the need for economic and financial reforms ahead of the G20 meeting, or as it has now been rebranded: the London Summit. An opportunity to redress global imbalances? Not bloody likely. I’m more inclined to believe this pithy observation from the Financial Times: “A crisis-torn world is in no mood for the heavy lifting of global rebalancing. Policies are being framed with an aim towards recreating the boom. Washington wants to get credit flowing again to indebted US consumers. And exporters - especially in Asia - would like nothing better than a renewal of demand led by the world’s biggest consumer. It is a recipe for disaster.”

So writes Zoe Williams in the Guardian newspaper. To be fair, she is taking a swipe at the UK government’s latest wheeze: cognitive-behavioural therapy for anyone finding themselves unemployed in the recession. I’m no CBT evangelist myself and think it gets an all too easy ride, often at the expense of other talking treatments. It’s no quick fix and certainly not a panacea. Like other evidence-based treatments for anxiety and depression CBT works for some people but not for others, and I am not at all convinced that Lord Layard’s army of CBT therapists will cure the nation’s ills. However, Ms Williams’s assertion that cognitive behaviour therapy is bogus is frankly, er, bogus. In fact this article is typical of the lazy, ill-considered journalism that serves to reinforce the stigma that shadows mental illness and its treatment.

I appreciate the difficulties of unravelling professional jargon in a short newspaper article but her attempt to describe CBT in a prison workshop is laughable: “[it] dismantles cognitive illusions, of which prisoners have many (among them high self-esteem, which causes them to esteem their own needs over other people’s)”. Does that make sense to you? For a rather more comprehensible explanation of cognitive-behavioural therapy have a look at this leaflet.

The next step of course is to rope in a guru, in this case the ubiquitous Oliver James, a psychologist who reigns supreme in the field of media-shrinks following the excommunication of Raj Persaud. Apparently James is the pre-eminent anti-CBT fury [sic] and his evidence for the bogus nature of this treatment? One study published in 2004 showing that after 18 months CBT was of little benefit in comparison to no treatment, James summarises, “CBT gives sufferers the illusion that they’re feeling better…it’s hypnosis basically”. Actually this paper isn’t a study or a trial of CBT. It’s a review, a critique of the problems involved when using randomised trials to provide evidence for talking treatments in general. Not quite the same thing then…and no mention of hypnosis either. There are however, an increasingly large number of trials and reviews of trials showing that CBT does work particularly well for anxiety disorders, but also for depression. Rather than relying on one expert and one paper you might be better off sticking with Google.

When it comes to discussing health, the Guardian journos might learn a thing or two from the oft-maligned Red Tops. Take a look at these pieces by ‘Dr Keith’ of the Sun on epilepsy and risk: clear, concise, and importantly, comprehensible.

I recently stumbled across the homepage for The Prince’s Foundation for Integrated Health and found this. Yes, HRH is coming to the rescue of mental health services in the UK by introducing guidelines on nutritional therapy, reflexology and aromatherapy. No specific mention of homeopathy or intercessory prayer but we live in hope. These guidelines will “set out the governance infrastructure for bringing these therapies into NHS mental health services and will provide a guide to service development”. Prince Charles’s partners in this venture are the Mental Health Foundation, Mind and of course the Royal College of Psychiatrists (of which he is the patron). The guidelines are due to be published in May but the funding comes from Lloyds TSB…oh dear.

St John’s wort has been discussed here before, but if you want a balanced overview of complementary treatments in mental health, Ursula Werneke’s article in Evidence Based Mental Health is this month’s Editor’s Choice (so it’s free to access). For a slightly more jaundiced view of alternative medicine in general David Colquhoun’s blog is well worth a look.

Start with a curry, followed by chocolate with red wine and tea. Toss in some grilled vegetables with olive oil (Mediterranean diet) and a Nintendo DS, to be played with not eaten of course, and you will be practically dementia-proof. OK, maybe not, but the chances of you developing Alzheimer’s will be significantly reduced…won’t they?

‘Foodstuff prevents dementia’ seems to have become a genre of epidemiological study and a new one pops up with a press-release every few weeks. I’ve just noticed this one on the BBC Health website, ‘Vitamin D is mental health aid‘, so it may be time to head for the sun or failing that, gorge yourself on some fatty fish. You can take a look at the abstract here and - surprise, surprise - the usual flaws are present. Firstly, it’s a cross-sectional study, so they have found an association but causation doesn’t come into it. And were they looking at dementia? No, the survey included the Abbreviated Mental Test Score which is a 10 point screening, and not diagnostic, tool for cognitive impairment. To be fair to the researchers, they do point out these limitations (along with several others) in their paper but it always seems to get lost in translation. And just to make sure you don’t miss the dementia link, these articles never appear without a spokesperson from an Alzheimer’s charity calling for more research.

I do wonder where these epidemiologists get their research ideas from: trawling the local supermarket? Of course there is only one sure-fire way to avoid dementia, as The Who memorably sang…and no, it wasn’t ginkgo biloba.