3.4 Professor James McCormack - Bohemian Polypharmacy

Aural Apothecary Episode 3.4

Jamie: Welcome to the Aural Apothecary podcast. My name is Jamie Hayes. Coming up in today's episode, we're joined by Professor James McCormack. James is a pharmacist and professor at the University of British Columbia in Canada. About eight years ago he did this...

*Polypharmacy parody of Bohemian Rhapsody* https://youtu.be/Lp3pFjKoZl8?si=-KhmGHaV-mMfEqqb

Jamie: We will welcome James in a moment as he shares his desert island drug, his career anthem, and recommends a book for the Aural Apothecary library. Our micro discussion this episode will ask, is it relapse or withdrawal? As we look at antidepressants and the role that social media is playing in helping patients understand their symptoms.

Quick apology to our own patient and public audience. Look, we crept into the red zone on the “jargon monoxide” monitor with our last episode, we will try and keep an eye on things this week. Let me welcome my two fellow Apothecaries. STC is in Bournemouth and Gimmo is in Cardiff. Welcome both.

STC: Evening.

Gimmo: I'm thankful that, even though we can see each other on Zoom, no one else can, because I've just had to watch you two air guitar and sing along, which was, you know, it's like watching your granddad at a wedding.

But, yeah, good couple of weeks for me. Busy. There was something on Twitter. I forget his handle, now. And he was describing the general mood in the NHS at the moment, and it is grumpy and tetchy and I think that sums up quite a lot of people I've talked to and people I know is it's busy out there, isn't it?

Everyone's really, really busy and stretched and a bit grumpy and a bit tetchy, so hopefully we can cheer them up with a bit of podcast and read a great book,  this week it's called To Sell is Human by Daniel Pink. Have you read it? Very good. And his basic premise is that if we work in health or education, we are salespeople. And so, we need to learn from the techniques of selling, lot of behavioural stuff in there, which is stuff we've talked about before.

Jamie: We are all in sales, isn't it? That's what he says. Yes, we are all in sales. Yeah. Read it. Love it.

STC: Not surprised Jamie's read it. Is there any book you haven't read?

Jamie: There's a few. There's a few.

STC: Have you got a job?

Jamie: Oh, don't go there.

STC: Oh no. Okay. Well listen, I thought it was about time I recommended some more podcasts for the listener, particularly with today's guest. And so, you've heard me talk about the Freakonomics radio stable Steven Dubner. Well, he's got a new one out called Freakonomics MD and it's fascinating because there's a guy called Dr Bapu Jena and not only is he a doctor, he's an economist, so he takes a really fascinating slant on things to do with healthcare, but from an economist's point of view, and so I couldn't help but mention these last two that came recently.

One was looking at a load of data. This is fascinating. He compared, what are your chances of dying if you were admitted to a hospital with a heart attack or a cardiac arrest on the few days that a lot of cardiologists in America are out of town and they're attending an annual conference for cardiologist.

It was a proper study and they looked at the number of days and they looked for so many years afterwards and so many years before. And actually, the mortality rate was lower when the cardiologists were out of town, and the second one was made me think about Chris Martin the other week. Talking about community pharmacists and how they could really do more clinically, and this is a fascinating one because a pharmacist was working in a barbershop, so they were worried about black men in LA and how they didn't interact with healthcare, and they went and set up like a healthcare hypertension clinic and welfare clinic in the barber shop. So, the barber was introducing and getting people to come in, and then they were all getting their blood pressure done and they had some great stats about how they managed to reduce their blood pressure and such like, so it made me think about community pharmacists, like barber shops, communities, eh.

Gimmo: So something similar like that was done up in Caerphilly where they put sort of wellbeing clinics in in the man's clubs. And the pubs.

STC: Yeah, it's impressive.

Jamie: Very good, not much from me. I just wanted to point out for our keen listeners last episode, our guest, Dr. Sally Lewis, was recording the session in her very glamorous shed, her garden shed, and with that came the sound of very soothing and calming running water from the stream next to her garden.

So if you have listened to our previous episode, that might have been the mindfulness exercise that we added in as a bonus to that episode. It's been conference season for me, so I've been chairing a few conferences and had the pleasure to introduce Sally, our previous guest, but Dr. Julian Treadwell, Alpana Mair and Mike Scott at the PrescQIPP  annual event this week as well.

STC: So without further ado, we've talked about podcasts and how we'd learn from podcasts ourselves. So now's the real reality check that we decided we should invite on somebody who has done nearly 500 podcasts. He's from British Columbia in Canada. I certainly spent a lot of time listening to his podcasts and absolutely love them.

I'm not gonna say that we ripped off anything to do with them, but he does use humour as well as evidence, and it's himself and a family doctor, I think is otherwise known as a GP in this country, called Mike, and as I say, it's Professor James McCormack, and it's an absolute pleasure to have you on, James. So, just for the listener, you did your pharmacy degree in 1982 in British Columbia, then you did a pharmD in South Carolina, and you've got a lot of experience, not just locally and nationally, but internationally, talking with health professionals and consumers about the rational use of medicines.

And not only have you done nearly 500 podcasts to do with medicines and healthcare, but you've done nearly 500 seminars and all sorts of things. And your big passion is around shared decision making and evidence-based medicine. Is it not?

James McCormack: Yeah. No, exactly. And thanks for the invite. I really appreciate you guys having me on.

It's somewhat weird being on the opposite side of the microphone, if you will, where you're being invited to another podcast. But no, it's great. And I am passionate about shared decision making, but, you can't do shared without having, you know, a solid understanding of the best available evidence.

So, you know, our podcast is really about taking the best available evidence, making it easy to understand, or at least simple to understand so the healthcare providers can use it, because there's no way you guys can look at every study and try and put it into context. So, just as probably what you guys are trying to do, we try to become a source of information that is trustworthy.

As you said, you got to have fun when you do a podcast.

STC: Absolutely. And just for the listener, so it's called Best Science Medicine podcast, and the strap line I love and we can go the full hog here. So it's 'BS' without the 'BS'. So best science without the bullshit. We love that.

James McCormack: And you know, some people take offence to the word bullshit, but I'm unaware of any other word in the English language that I can use that gets that point across.

So it's, I think people get what we're talking about. And, the reason that's so important is because there is a lot of BS and it's not necessarily, and we'll talk about this maybe a little bit later on. Some of it is intentional, but some of it is just people saying things that they truly believe to be true, and so it's a very tricky process trying to weave your way throughout the bullshit.

STC: So what would you say was the number one thing on your agenda right now?

James McCormack: You know, the number one thing on my agenda really is about how do we take the best available evidence, make it in a form that patients, clinicians can understand and have you healthcare providers, if you will, use that information because there's no point in us doing podcasts or creating synopsis of evidence that people can't use them and interact with them.

And so I work with a really, really good group here in Canada, some in BC but actually all the way across Canada called the Peer Group. And it's all about, for the last maybe 10, 12 years is we've attempted to disseminate information in a way that's understandable, that's simple, that's short, but right to the point.

And we've also gotten into the whole writing guidelines, even though I'm dead set against most guidelines 'cause they sort of tell you what to do. But we've written a number of guidelines because we felt that the national guidelines, we're not doing what they're supposed to do, which is provide healthcare providers with the best available evidence and help them help patients make decisions.

STC: And Canada leads the way, does it not in relation to de-prescribing. So again, for the listeners, sorry if we're using jargon monoxide again, but reviewing and stopping people's medicines, Canada leads the way, doesn't it?

James McCormack: Well, I don't know how you figure out if a person is the leader of it. We do a lot of it, and I think, you know, there's a de-prescribing group here. Even the term de-prescribing I'm trying to go away from, because it sounds quite negative, right. I mean, I think you guys maybe even mentioned that on previous podcasts where there are lots of medications that are very helpful, but there are a lot that aren't, and there's a lot that are very helpful but they're not used the right way.

And so I worked with a group in the States about a year and a half ago called The Loan Institute, and we came up with sort of two phrases that they actually did some sort of consumer evaluation and asking people what do they think of things like de-prescribing and polypharmacy, and consumers didn't understand those words at all.

And so they came up with a really cool way to think about it. And one of it was medication overload. Are you on too many medications for you? How do you put that in context? And then rather than de-prescribing, they came up with a really cool term. Again, it was called either medication or prescription check-up.

STC: Yeah, well, MOT we have in England, you know MOT for a car?

James McCormack: Yeah. So I think the, it just sort of shows how careful we do have to be with words. Because, I'm sure you guys have enough experience where, you say, you know, we're gonna try and de-prescribe, sometimes people say, oh, you've just given up on me.

Well, no, it's not that it's the exact opposite, when we do that, but the term is not a great one.

Gimmo: It's often viewed over here as rationing or, you know, you're just doing it to save money. Yeah. Because I think there's still a general. Perception is more is better, isn't it?

Jamie: Let's not be too hasty, James, with getting rid of the term 'cause I bought de-prescribing.co.uk about four or five years ago and I still haven't done anything with it yet, and I'm still looking for somebody that-

STC: I told him not to buy it.

Gimmo: I'm buying medicationoverload.com as we speak.

Jamie: Yeah. Yeah. But you're right, James. Language is important, isn't it? And I introduced Julian Treadwell this week, at a conference, and Julian was describing his work on literacy skills and risk skills of GPs in this case.

And I noticed that you were down as one of the expert advisors on his paper and his research.

James McCormack: I was gonna say, I know Julian. I've met him a few times, and I also, you know, we get to know people with groups that we work with and no, he's brilliantly good. And, you know, he's such a, an advocate of all of the stuff that.

I know what you guys are doing and what we're trying to do, and it's really important that we have that voice in primary care to try to do that because you guys know as well as I do, 95% of all medications are part of primary care. It's not the specialists, it's not in hospital, it's primary care.

And so that's where the problem lies. I mean, an example, when you see a person going into the hospital with a heart attack, they come out on seven drugs, they're all evidence-based, but they're also all prescribed at the same time and they're in a bed lying down. So they have no issues with low blood pressure or low everything.

And so, we need to make sure that we look at these things in a correct way.

STC: Oh, James, don't get me started on single-organ-ologists. I dunno if you've heard me talking about cardiologists.

Jamie: Well, you've already had a dig at cardiologists tonight, so let's put that one to bed. So Julian's point was, and he was just reminding us that we overestimate the benefits and underestimate the harms in our decision making.

And so I see you on the over-diagnosis group, which I think the three of us are on as well, and very prolific on that. But I'm on the other, the Anorak group as well. I'm on the evidence-based one as well. And that one goes deep sometimes, doesn't it?

James McCormack: Yeah, it does. And it goes deep for that group. And that's brilliant.

But we have to be so careful that, when I started all this, we thought one of the things we wanted to do was, why don't we train everybody to do evidence appraisal? And that's a complete disaster 'cause no one has time to do it. What we do need to do is we need to say, here is how evidence appraisal is done.

Not get into all of the nuances of it. But then allow people who are busy everyday healthcare providers access to trustworthy synopsis of evidence so that they can use it. Because you know the nuances that you can get into evidence-based healthcare, it's much of the time, I'm not saying it's not important, but a lot of it is just mental masturbation.

And I don't know if we need to do all of that all the time because what we do need is a reasonable ballpark estimate of the benefits and harms of medications. And that's what we try to create.

Gimmo: And that's similar to what Dave Slawson said, wasn't it? In the episode last series, was about you don't do the evidence appraisals yourself, trusted sources of information, develop people that you trust and use summaries that are from a source that you can rely on rather than even attempting to keep on top of all the information that comes out.

James McCormack: Yeah, no, I agree. And I met Dave there I think once or twice, and he and his gang are doing a lot of what we are doing. What I think is really important to realize is that for healthcare providers, yeah, I'm sure it feels overwhelming, but I can tell you right now, if you're in primary care, you can find, you know, synopsis of evidence that are useful for the vast majority of things that people do.

And I would suggest that, if you as a healthcare provider are not at least somewhat familiar with the best available evidence around the top 10 or 20 things that you see on a day-to-day basis, I actually don't know how you practice. And it's not that you have to be able to quote it verse and passage and know everything to do with a Bonferroni procedure and statistical manipulations.

No, you don't need that. You need to know - If I didn't treat, what's the risk? And if I do treat, what's the risk? And if you know those two things, ballpark, boy, can you ever have a great discussion with patients, and not only patients, at least you now understand it versus saying, "oh, I treat blood pressure, 'cause I always have."

STC: I think you've got it in a nutshell there. And I say can't speak highly enough of James's podcast with Mike. And so for listeners who are interested, look it out.

Jamie: Did you say mental masturbation?

James McCormack: I did and I made sure that I added the word mental.

STC: Yes, that's okay. And did you notice that until Jamie just said that we were all thinking of the same thing?

Shall we make light of this?

Jamie: Before we move on, James, I introduced the parodies that you are well known for that 191,000 views on YouTube for the ' Bohemian Polypharmacy' one. Just tell us a bit of the background on those.

James McCormack: Well, again, I'm a tenured professor and I can do whatever I want.

I like music and I'm always trying to find creative ways to disseminate information. And so way back when I think I've probably seen a few parodies. I don't know how these things come to one's mind. I mean, how did you guys all of a sudden figure, let's do a podcast. There's something that happens with that.

And I play around with music. I dabble on guitar and keyboards and I play around with it and I just thought it might be fun. And I put out one and I, we actually maybe talk about it in just a few minutes, but I put out that was quite popular about evidence. And I went, huh, isn't that interesting?

People like that. And as we've talked about, we could have two people talking about the exact same topic. One is really boring, you don't pay attention. And one is more entertaining or interesting in because we have to realize there's very little difference between education and entertainment. You need to be able to do both.

If you want to do either well.

Jamie: If they're laughing, they’re learning.

James McCormack: Yeah, you know, you have to be, uh, somewhat careful. There are a few topics that you maybe shouldn't always laugh about, but there's not many.

Jamie: Can I indulge, just and play another one? 'cause I've queued another one up. Just a few seconds.

*Parody of Day Tripper by The Beatles* https://youtu.be/XXMcDtOO7NI?si=E6aL7uNa48BalEBE

James McCormack: Thank you. Well, thank you again for playing those. They are fun and, and often people ask, do I sing on those? And the answer is yes and no. The ones that are really popular and really good, no. There's about two or three, that I do. And the reason, one, I'm an okay singer, but I'm not that great of a singer.

And the Bohemian Rhapsody, there's about 0.1% of people in the world that can even come close to singing that. And so for some of them, I have got some really good guys who can really flat out sing. And I do that because you want the quality, 'cause if the quality sucks, it's not good.

And so it's all about providing quality, trustworthy information, if that makes sense.

STC: Just like the Aural Apothecary.

James McCormack: Yes, I would not argue with that.

Gimmo: No. The, the term polypharmacy isn't a term that even, pharmacists struggle to get each other excited about it, but I've used that Bohemian Rhapsody polypharmacy video at talks and conferences and it's just a great way of engaging people on a topic that is really difficult to actually articulate what the problem is.

James McCormack: Yeah, no, and I agree, but, and it's partly the problem of the polypharmacy, 'cause you know, people define it, is it five medications, is it 10? And it's really easy. It's if you are on more medications than you need, you have polypharmacy. I mean, it's really simple. You could be on one and that's polypharmacy if you didn't need it, or it's the wrong dose or whatever.

So I think it's important that we talk about medications and not be it's five or it's four, or it's this, or it's that, because I think that takes us down the wrong path.

STC: Okay, James, I'm already loving this episode, but I'm really looking forward to your choices now.

So, I think you might know if you've listened to the Aural Apothecary that we ask you for three things as a guest, and the first one is a desert island drug, which is a drug that evokes a very powerful memory for you, not something that would save you or somebody else on an island.

James McCormack: Yeah. So you probably noticed that I don't always follow the game plan of everything, but I am gonna work on this one a little bit.

I'm gonna work my way through a few things here. My Desert Island drug, believe it or not, is an Aminoglycoside. And you're probably going, why the hell is that? And the reason is, is because the reason I do everything I'm doing right now is because I was taught by very smart, very passionate, very kind people to do Aminoglycoside levels.

And when I started practicing, I went back and looked at some of the evidence about having a therapeutic range. And it was awful. I looked at one study and I read through it and I didn't know how to evidence appraise. This was before evidence-based medicine. And I looked at it and I went, that's not a very good study.

And I just assumed that must be the worst one. And it was the best one. And it got worse and worse and worse. And I realized that we do things in medicine without evidence, but it's not done intentionally. And so we wrote an article in 1992 about that saying there's no evidence really whatsoever for a therapeutic range for aminoglycosides.

And then we did another thing in 2000 where we looked at the levels of aminoglycosides in once a day use of aminoglycosides. Not only is the evidence terrible, there is none, there's not a single study. It is literally made up. So that's where I got with that. Now, the only other drug that I put in there, 'cause I don't really want you to put Aminoglycosides in there, is low doses.

And that's any drug that is a low dose because the evidence is outstandingly clear that we get almost all the effect from really low doses. So I don't have a, it's not a desert island drug that you should do, but it's fundamentally changed how I practice, is starting off with low doses and I'm not talking the smallest tablet version.

I'm taking the smallest tablet and cutting it in a quarter or an eighth because the evidence is overwhelmingly clear for that. And then one final one is, if you're really interested is about three years ago we asked a whole bunch of family docs and pharmacists. We said, if you could only have 20 medications, what would they be?

And we went through a variety of iterative processes and we came up with 20 of them. And the most fascinating thing was the mean date of release of those drugs was the mid 1950s. It was drugs like...

STC: Amitriptyline ?

James McCormack: Yeah. Amitriptyline didn't make it because we have other ones that you could use, but morphine and insulin, furosemide, lorazepam and all of those, those are the thought processes around my drug.

And I know I didn't follow your perfectly outlined process, but I wanted to get those messages across.

STC: Well, I, I tell you what, 'cause I know it's on your website and you are talking about your top 20 most valuable pills of all time, aren't you? So maybe we can give you the top 20 most valuable pills as your desert island drug.

Because you're dead right, when you look through them, those are the ones that you're talking about?

Jamie: No, no, no. That, that drives a coach and horses through our formula.

STC: So we'll go with a aminoglycosides then.

Jamie: Yeah. Gentamycin, it is James! Thank you, haha.

James McCormack: Oh God. But there's so, so much of a caveat to that.

Gimmo: Isn't it interesting that, so there's a phrase that's bandied around in improvement and you know, it's not, yeah, you could argue with it, but it the perception that this is the way we've always done it. So that's why we're doing it that way. That normally applies to practices as opposed to specific clinical interventions like giving someone a drug.

I mean, it just shows you how dangerous it is that we do things the way that we've always done it. 'cause that's sort of just behaviour being reinforced over the decades, isn't it, really?

James McCormack: Uh, well it is, it's an unnecessary distraction 'cause it took hours of time to do the levels and everything. Over the years, I've been involved in probably 20 lawsuits, not against me.

But as an expert witness where, you know, people were on Aminoglycosides and they got life altering vestibular damage, and the levels were perfect. They were just on the drug inappropriately, on way too long. I'll be honest, when I started practicing, I didn't monitor for anything to do with ototoxicity or anything like that.

 I just, it wasn't part of what we did, but, boy, did we get those levels perfect.

STC: Okay, well, we'll use Gentamycin, but we like your story and we like the ethos of what you're talking about, which is about using the lowest possible dose, for the shortest period of time, I would add to that.

James McCormack: Except in life-threatening conditions.

Jamie: He's backtracking now. He's backtracking now.

Gimmo: For anyone listening, don't use half of an EpiPen.

STC: Right. Okay. Now I'm also very fascinated to hear this then, particularly 'cause as we know about your musical parodies, we also would like something for our Spotify Aural Apothecary playlist. And this is a career anthem.

So what would you like to give us? You've only got one.

James McCormack: Yeah, and I'm only gonna do one, but there's a caveat, you know, uh, you guys had Chris Martin on last podcast, or was it, or two podcasts ago. And I was terrified when I heard, 'cause I thought he was gonna choose a song I was gonna choose.

And I chose Viva La Vida by Coldplay. And the reason I did that is if you look, if you just listen to some of the words in it, there's a slight anti-authoritarian viewpoint that comes across with that. And so, as some of you may know, Ti hink the most popular parody that I've done is of that. I thought I might just give you maybe 10 seconds of the words that I put into that song because it really does, it's the anthem of how I like to think.

"I used to view the world as a place where I gave the word. It had the feeling of eminence. But then along came evidence. I used to give advice, see disarray in my patient's eyes. I listened to the company sing. Now the old drug is dead. We got a new thing. One minute I held the key next to walls were closed on me, and I discovered that my practice stands upon pillars of salt and pillars of sand."

And that really in my mind is why I do what I do. And I think probably somewhat why you guys are doing what you're doing.

STC: Powerful stuff. We haven't had a Coldplay track. We did have Chris Martin on.

Jamie: Did your great-grandfather write that though, James?

James McCormack: He did, yeah, he did. He's still alive. He's 192 and he's, never been on a cholesterol lowering medication or cared about what he ate.

STC: Okay, so Coldplay, Viva La Vida definitely makes it into the Aural Apothecary Spotify playlist. And the last one, again, I'm interested to hear about this, this is something for the listener that you might recommend as a book for the Aural Apothecary library.

James McCormack: Yeah. Well, back in, in 1992, I was just sort of getting into being a Professor at the university and trying to think I was very smart and trying to be, you know, very clever about things, and I watched a documentary called, Manufacturing Consent, Noam Chomsky in the Media. I don't know if you're familiar with it, but it was a really interesting film. I am gonna get to the book in a minute, but it was the film that turned me onto this whole process about what they call the propaganda model of communication.

It's a really interesting look at why do we end up doing Aminoglycosides, he didn't talk about Aminoglycosides, obviously, but why do we end up in a situation that we're in, the film talked about the systems that we have in place lead us to a pathway that we do things even though the people are good and they're not necessarily trying to be evil. We end up in a situation where we're doing things that we shouldn't be doing.

And so it's talk about the sort of the mass communication media of the US and they say everything is in place. You don't need coercion to have a problem. We too often blame drug companies and the government and all that, but it's, it's, it's not that they're all trying to do bad things, it's just the, the way that we think about things in general.

So that led me to the book called Manufacturing Consent, the Political Economy, the Mass Media, and it's a book that was put out in 1988. And it's really for us to think about is that it's the system that is the problem, and it's not some evil overlords that are doing it. And so when it's systemic problem, you have to come up with systemic solutions, telling people that they're bad prescribers, talking about polypharmacy as if it's evil and all that is not the way to go.

We need to stand back and think about we're all in this together. You guys can tell me, I have yet to meet a healthcare professional that I think is really awful. There's maybe one, but they're all there trying to do a good job, and the system is very difficult to work around. So that's why that book was so important to me, even though it had very little to do with healthcare, but it had everything to do with messaging and propaganda and all of that sort of stuff.

Gimmo: And it's interesting that that's 1992, you said. We've been talking about everything that you've just mentioned over the last podcast is as if it's new.

James McCormack: There is nothing new. You could go to 1892, you could go to 1792. The way that systems and actually the way humans react. I mean even if you think about it, it is way harder to do nothing in healthcare.

That's because we're relatively nice people trying to go give people a treatment, when in fact, the best thing is sometimes, as you know, “don't just do something, stand there”.

Jamie: Hope in the form of a pharmaceutical, isn't it?

James McCormack: Yeah, and this is one of my pet peeves. I'm not sure exactly if it works this way in England, but I think if you wanted to set up a system where you ensured the worst medication use possible, you would pay people to give out medications and you could fix it really, really quickly.

You'd fix it in a, probably an equally bad way. You could say, instead of giving you $10 or £10, or whatever it is to dispense a medication, we'll give you a thousand to not dispense it. If we did that, there'll be a fundamental shift within about a second of how we use medications. If we go too far, the one way.

But isn't it interesting that that would probably be the thing that could really change it?

Gimmo: And they did try that, didn't they? Jamie? And there's a trial in South Wales somewhere where they paid people not to dispense. It was called, the not dispense scheme?

It did work, but I just think it goes so against the grain for paying people not to do something that they were never funded or expanded.

STC: Okay, great. James, we will try and look that book out if I can remember the title, but it was very long. So you'll have to tell me afterwards.

James McCormack: I will. Yes

Jamie: And, 1992, a very important year 'cause it's the year that Steve and I qualified.

It's very good. Okay, our micro discussion next . We're discussing a couple of opinion pieces that appeared in the British Journal of General Practice. This one caught my eye 'cause I liked the title, so I'd be interested to see what James makes of it. "Four research papers I wish my GP had read before prescribing antidepressants" and it's from a researcher and service user.

It's quite a powerful piece that goes on to describe how over 17 years of being stuck on these medicines, these four papers explain that journey. And then the second additional paper, which adds to the mix is Tapering Antidepressants: why do tens of thousands of patients turn to Facebook groups for support?

What do you think, James? Have you had a look at them for us?

James McCormack: Yeah. So there's a whole bunch of things around that issue, and I think the very first thing that we need to talk about when it comes to antidepressants is, How effective are they in the first place? Because I think we have to go down that path first to, to understand why we sometimes need to get people off them or people come off of them.

The evidence is, that is overwhelmingly clear. If you give an antidepressant to a person about 50% of the time, they will either no longer be depressed or be less depressed. In six to eight weeks. The problem is, it's 40% in the placebo group. And this is not the placebo effect, this is just the natural fluctuation of the condition.

It's regression to the mean. I know I'm not supposed to say regression to the mean, but it's that. So when you see a person who responds to an antidepressant, the vast majority of them, it's not because of the medication. So that's a conundrum we run into as healthcare providers, 50% of people will benefit, but 40% or 80% of that 50% are not benefited because of the drug.

And now we have to figure out, are you actually getting a benefit from that medication? And it's very, very tricky. And then the caveat is, and you guys know as well as I do, and you've been on pretty much every psychiatric medication that has ever been put on the market. It's always initially never addictive and you never went through withdrawal from them.

And we now know almost all of them are addictive and almost all of them, you go through a withdrawal somewhat. And so, we see exactly the same things with, in particular SSRIs. And I think it's really important to realise, and it's one of the reasons why we put together a website called MedStopper, was to give advice about how to stop medications.

Because you guys know as well as I do, that there's no book that tells you how to do it. You know, you do it in whatever way you know. If you go to some guidelines they'll say with getting off antidepressants some people will go through withdrawal and it's mild to moderate symptoms.

It's actually not that. So, there's two other really cool pieces of information. If we attempt to taper people off, and there's been a couple of randomised controlled trials of that have looked at this. If you try to taper them off, if you randomize them to taper or no taper, about 25% of people will have a recurrence of depression over 18 months if you leave them on them.

Approximately 10% will have a recurrence of depression. So it shows you that about 10 to 15% of people are actually getting a benefit from it, but 75% aren't. And we also know that the evidence is fairly clear that about half the people can just stop these drugs without any problem, but about half of them have withdrawal symptoms and about, you know, probably a half of that half are quite severe. It takes a long time to get people off these medications and you have to do it relatively slowly with small changes in the dose. And I think the reason that people are going to Facebook is because we've done a terrible job of telling people that this is a potential thing to do, and when you have 50% of people going through withdrawal, when you stop them, there's gonna be a lot of people on Facebook that are saying, boy, this has been tough. So that's my very long take on it.

Jamie: If only we had a frontline. If only we had a frontline clinician on the call with us tonight. James, let's go over to him now.

STC: Well, you're spot on.

Jamie: What, you are a frontline clinician?

STC: You see all of that, you know, every day I'm talking to people who are either, trying to come off or have had problems with “electric shocks in the head” is the way that most people describe it, the symptom that they get most.

And they really notice, particularly if they haven't been able to get their prescription filled and they're off it for a few days and they, you know, they're really noticing it. And so, like you say, it's a bit like when you said about starting drugs, starting with the lowest dose, you are saying the evidence says 50%, but for some patients you can stop it relatively quickly if they haven't been on it very long.

But for others, I've got patients who, you know, I'm holding their hand to come off those things over months and years.

James McCormack: Absolutely. Yeah. No, no. You're exactly right.

Gimmo: And you mentioned earlier, James, just before about how the Aminoglycosides, how, you know, if you say something enough or it's practiced enough, it's believed.

So I qualified a few years after Jamie and Steve, but not that many. So Fluoxetine was the big, 'I am', the big drug then. And it was massively marketed on the fact that it didn't have dependence and withdrawal effects and was for years. So I must admit, I find it hard to change my mindset on that issue.

Even hearing everything you've just said then, and reading these papers and seeing it first-hand is it's a real bias, isn't it? That we still have this sort of mindset that drugs like this don't have withdrawal effects. And so, I'm guessing if you are a busy GP, faced with a patient who's got depression or other issues, and you've got no other options because there's no mental services to refer them to. The after effects aren't on your mind at that point of prescribing. I doubt you're thinking about withdrawal at that point of prescribing.

James McCormack: I totally agree with you. The interesting part about it is though, I think it's really important, and again, this almost goes back to the thing that I was talking about with that Noam Chomsky book is, even the word depression is not a good one.

I know a colleague in New Zealand that I've done some work with, Bruce Errol, he's a great researcher in primary care. He said, we have to stop using the word depression. I mean, it's so label oriented. He said, and I think it's a brilliant word to use, is you're stuck, aren't you? You're stuck on something.

Whatever it is, you're stuck and we need to get you unstuck. I think healthcare providers need to know the benefit of these antidepressants is about one in 10, and all you have to do is then you need to be very fully aware of the side effects. We just talked about withdrawal symptoms.

People get side effects from being on them. Sexual dysfunction with these medications. I think the number in women is around 30%. And if you just even look at the list of the withdrawal symptoms, I mean, it's awful. And I think we need to be so careful with this, and one of the things, the messages that I think are really important is we should never put a person on an antidepressant in the first visit.

And that you guys know as well as I do, that happens a lot. I don't think it happens all the time, but we have, there are so many other things we can do for people who are stuck. Exercise is just as effective now. I understand exercise and activity is not always possible for everybody, and when you're stuck or depressed, you don't feel like doing it.

STC: You might not have heard the episode and some of the listeners might not, but if you haven't, I would suggest you'll go back and listen to Dr. Karen Sankey, who was, I think episode three in series two, who's a GP, who works with the homeless, but she talks a lot about, as you've just described, she didn't use the word stuck, but she was saying that she felt helpless as a GP 'cause all she had was her pen to be able to prescribe an antidepressant. And she knew damn well that for a lot of those people, that wasn't the right answer.

James McCormack: Yeah. Another cool thing around being stuck or depressed is to create realistic goals. And again, this is stealing from my friend and colleague Bruce, who said, have the patient and identify something that they are likely gonna be able to do.

You know, if it is, I haven't had the energy to go outside the house, you might say, well, is there at least a 70% chance that you could do that one time this week? 'cause if they can't say it's 70 or 80%, you're gonna set 'em up for failure. So you identify the thing that they say, I think I'm likely to do, but if they say it's only 10% chance, they're just gonna fail and be more stuck or depressed.

And so, sorry, I didn't mean to interrupt you Paul, but go ahead.

Gimmo: No, no, that's fine. In last week's episode, we, we talked to Sally Lewis who talked about value-based healthcare and how you can spread that investment across the system in a better way. I think one of the pieces of work that was referenced in those papers was the Public Health England analysis in 2018 and it showed that antidepressants were prescribed for 7.3 million people in the UK or that might even be England, I think. So that's 17% of the adult population had an antidepressant, and so, what Sally talked about was we invest in the wrong areas of the chain.

I'm sure it's the same over the pond. There's a chronic underinvestment in counselling services, in mental health support and psychology support and stuff. And so, we invest all our money in the drugs and not, which you've described very well as, you know, not that great and not at all in the talking services where I think we've got a far better evidence base for, so it's another example of what Sally was talking about, of the investment being in the wrong place.

James McCormack: Yeah. And a pill is an easy fix, and to tell you the truth, I mean, If I was, I don't know, depressed or anxious or whatever, and there was a pill I could take and it had no side effects and no cost, I would take it. 'cause a pill is easy to take. A colleague of mine, who I learned a lot from as I was getting into practice, said “a drug without a side effect, is a drug without an effect”

You know, I think we, we need be aware of that as an issue when it comes to medications, especially when it comes to drugs like the SSRIs for which we have no clue how they work, but we do know they effect oodles of different neurotransmitters in your body. And then we go, Holy Cow! , that's surprising that it was difficult to get off.

Jamie: Gimmo's mentioned the Sally Lewis episode. Sally's book was Reckoning with Risk, James, and I mentioned that the first chapter of that changed my teaching 'cause I put a lot of scenarios in, but one of them I remember changing at the time and it was the Prozac example of sexual dysfunction. And it says, only then did the psychiatrist realize that he had never checked how his patients understood what a 30 to 50% chance of developing a sexual problem meant.

It turned out that many of them had thought that something would go awry in 30 to 50% of their sexual encounters. For years, my friend had simply not noticed what he intended to say was not what his patients heard.

James McCormack: Yeah, well, I've got a great example of that where I can't remember what it was, antibiotics or whatever I was talking about, and they said, you know, the chance of diarrhoea is about 10%.

There's more than just one person who thought that meant. Every 10 times I go to the bathroom, I get diarrhoea. And so, that in and of itself is, you know, I'm doing the best I can to give numbers and talk about side effects. But you know, here's a wonderful, I think it's an example that we should take from this, is we were always trained as healthcare providers, let's say if you're gonna use  uh...

STC: Salbutamol?

James McCormack: Yeah, salbutamol And, yeah, we always are told, show a person how to use an inhaler. And then get them to show it to you because you know, the first time you show it, they're not, they just can't do it. And so we need to do the same thing. When we explain evidence, 'cause you know as well as I do, we, when you've got a person, they go, " uh-huh I've not got a clue what you're talking about" and I try to do this all the time and say, what did I just say? And I don't mean that as derogatory. Just tell me what you think I just said, you know, as well as I do half the time. I gotta redo it.

Jamie: Look, I'm gonna throw one more at you, James, and it might be, it's a slight curve ball, but it is antidepressant related because I learned a lot from this gentleman over antidepressants and in particular, the influence of the pharmaceutical industry, professor David Healy. Do you remember when David came over to Canada?

James McCormack: Yeah. No, I know.

Jamie: Yeah. And so, I learned a lot from David 'cause he used to do a session on how a depressed woman was portrayed by the pharmaceutical industry over the seventies, the eighties, the nineties, in their marketing campaign.

And it was very clever the way that he put that together to show, look, this is what we are being sold here. This is what a depressed a woman looks like in the 1970s. And now look, this is a depressed woman in the nineties. And it was very clever.

James McCormack: Yeah. And again, if you owned a business, you would do exactly what drug companies do, you would promote, hopefully not doing something illegal, but you would promote it just like that.

You'd get to that edge as much as possible. So, we cannot blame the drug companies. They are intimately involved with the problem. But as a colleague of mine once said, when it came to using the latest and greatest, no drug company has ever put a gun to my head and told me to prescribe. And again, this is not to blame healthcare providers or us.

It's a systemic problem. And I think we need a systemic solution to this. And it will not come from siloing pharmacists or nurses or other healthcare providers. It's about all of us working together in conjunction with patients. And we are all gonna become patients at some point. So we need a system to be better than what we have.

It's not awful, but it's got a lot of room for improvement.

Jamie: Okay, A big thank you to James for joining us on the Aural Apothecary and for sharing his stories, his Desert Island drug and his career anthem, and a book for the Aural Apothecary library. Coming up next time we'll be joined by Dr Diane Ashiru.

Diane is Lead Pharmacist for the Antimicrobial Resistance Program at the UK Health Security Agency. That's Public Health England in old money and chair of the UK Antibiotic Guardian campaign. We look forward to catching up with Diane next time on Aural Apothecary. Over to Gimmo for the final ingredient.

Gimmo: Thanks, James. That was fantastic. It was last week, I think on Tuesday, International Pharmacy Technician Day. Who is the most famous pharmacy technician?

STC: Oh, good question. Is it Sam that we had on in Series one?

Jamie: The goat?

Gimmo: No. So during the First World War, Agatha Christie, who was a nurse, took a break from nursing to train for the Apothecaries Hall examination. She actually found dispensing in the hospital pharmacy monotonous and less enjoyable than nursing, but a new knowledge provided with her background in potentially toxic drugs.

There are many medical practitioners, pharmacists, and scientists in Christie's cast of characters. So check out Murder in Mesopotamia, Cards on the Table, The Pale Horse, or Mrs McGinty's Dead and there's drugs that feature in all of them. So, she said, I'm more interested in peaceful people who die in their own beds, and no one knows why. She used drugs such as arsenic, aconite, strychnine, digitalis, thallium, and other substances.

So, there you go. Agatha Christie's the fourth Apothecary.