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Feb 15, 2012

Ian Hickie: on Twitter, The Lancet and my critics

It’s not uncommon in my world to be engaged in very lively academic debates, like the risk versus benefits associated with new antidepressant drugs, writes Professor Ian Hickie.

It’s not uncommon in my world to be engaged in very lively academic debates, like the risk versus benefits associated with new antidepressant drugs.  Similarly, I have been widely attacked by a variety of vested health interests, particularly when I have argued for the clear cost-benefits associated with the range of new health initiatives.

It is more unusual, however, to be openly criticised, via Twitter, by the editor of a leading medical journal — particularly when that journal has just commissioned, peer-reviewed and published a major review that you have written. You can see here the Twitter feed of The Lancet’s editor, Richard Horton.

Basically, we reviewed a new drug class for treatment of depression, focusing on correcting abnormalities of the sleep-wake cycle. This is the type of depression that Andrew Robb has so bravely brought to the attention of the Australian community in recent years.

The review, published last August by The Lancet, drew some critical commentary from a variety of other international research groups, largely concerning what constitutes a real breakthrough in treatments in this tough area of medical practice. From my perspective, that part of the debate is fair enough – there are many unknowns that can only be sorted by further research and later clinical practice.

Quite separately, however, some have alleged that we had not declared our financial or professional relationships with manufacturers of one of the compounds — even though we clearly stated these at the end of the original article. Importantly, the editor never raised potential competing interests as a major impediment before publication. This is an area where the local critics continue to defame me by misrepresenting this process.

Given that we submitted the original article (as requested) in July 2009, and started returning proof corrections in February 2011, it was not possible to declare key educational or media activities supporter by Servier that occurred later in 2011. None have bothered to represent accurately my role in these activities, namely a focus on the biology of circadian systems and its potential value as a new target for depression treatments. Our expertise in these areas has been more widely shared with the general public.

Some of the correspondents went on to assert that we did not provide an accurate review of the relative benefits or potential side-effects of one particular compound, agomelatine, claiming that we were biased by our previously declared interactions with the manufacturer. This unfounded allegation was repeated widely in the Australian and international social media, with links being forwarded to my university for consideration.

Most of this would have passed without further comment if it were not for the tweeting behaviour of the journal’s editor, Richard Horton. Sadly, tweeting has not only replaced the academic journal itself as the major source of credible information — the new social media is perceived to be the place where people say what they really believe. Any allegation in cyberspace is instantly assumed to be true and relayed extensively throughout the social network that is modern media.

The content of the tweet is, in my view, clearly defamatory. Further, the journal has never provided a full account of its own role or the key dates over which interactions between us took place (July 2009 till May 2011). Consequently, I have lodged a complaint with the Ombudsman of The Lancet with a view to seeking a full retraction of the editor’s defamatory public statements.

My professional colleagues who conduct original research, our institutions, health journalists and many of the editors of Australia’s major medical and mental health journals, are well used to receiving these social media missives from the same small band of local anti-medicine or anti-psychiatry warriors.

Previously, a number of well known academics have not only contested the role that providing effective treatments for depression plays in reducing suicide but have actually objected to our work on the erroneous assertion that prescribing antidepressants markedly increases suicidal behaviour.

More specifically, attempts have been made by some to shut down our ongoing work with professor Pat McGorry, evaluating the effects of early intervention for teenagers and young adults at risk of psychosis.

More recently, our multicentre trial with colleagues from Australian National University evaluating a range of potential preventive treatments for depression in older people became a target. I was contacted by Jill Stark from The Age, who asserted that these same South Australian academics had labelled this trial “unethical”. No substantive grounds for that allegation were ever established.

More bizarrely, at least one member of this group has rung professional colleagues alleging that the Medical Journal of Australia published our original research without appropriate peer review.  The previous editor, Dr Martin Van der Weyden, made his rejection of that unfounded claim clear in no uncertain manner!

Sadly, Horton’s intervention has given renewed life to this broader anti-psychiatry campaign in Australia. The campaign here is designed not only to discredit the legitimate use of medicines, those practitioners who provide effective treatments and the experiences of those who respond to treatment, it is also clearly designed to derail the current round of national mental health reform.

Up to this point, we’ve avoided litigation and simply encouraged people to ignore the nonsense and back the reforms.

As reported by The Australian on Monday, the activists are now calling on the Minister for Mental Health to remove me from the new National Mental Health Commission over either undeclared competing interests — which were clearly declared — or my poor standard of academic work.

The irony of the latter accusation is particularly strong. First, the accusation comes from those who loathe active clinical research, health services innovation or balanced analysis of the available data. Second, as highlighted above The Lancet itself has just republished the same academic conclusion.

In response to that highly relevant article — no tweet from Horton. Of course, no retraction of his previous adverse commentary on the standard of our work. As a colleague wrote to me yesterday: “The editorial comments by Richard Horton, are at best disingenuous, considering he commissioned the review and had it peer reviewed. If his words are taken at face value, then it suggests that the editorial and peer review standards of his journal are not working.” Similarly, no public comment by our Australian colleagues on independent verification by The Lancet itself of the quality of our original academic work.

Horton has always been a controversial editor. He oversaw the publication (and later full retraction) of the research that proposed that the MMR vaccine was linked to childhood autism. He is also a regular contributor to The Guardian.

In recent times, he has become a real celebrity in the UK, due largely to the edgy nature of his tweeting (e.g. slamming the World Health Organisation) and his devotion to more politically correct campaigns on global health and development, mental health reform and the proposed restructuring of the UK health system.

Some feel that Horton is simply dragging The Lancet into the 21st century. Others feel that he has clearly thrown the academic baby out with the bathwater! To me The Lancet’s behaviour is considerably more commercial. In academe, as elsewhere, old-world publishers are rapidly losing the battle to free, online and open media outlets. Elsevier, the publishing house that produces The Lancet, is currently the subject of a worldwide boycott by some academics who are seeking a more open and transparent approach to the publication of science.

In my view, The Lancet, through the agency of Horton’s devotion to new media, is desperate to attract wider public attention before it goes out of business. From an armchair in central London, causing harm to individual academics, or a process like mental health reform in Australia, is a very minor concern.

*Ian Hickie is executive director of the Brain and Mind Research Institute at the University of Sydney.

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22 thoughts on “Ian Hickie: on Twitter, The Lancet and my critics

  1. Steve Gardner

    Dear Professor Hickie,
    Would you consider joining your academic colleagues in the boycott of closed academic journals, and publically committing to publishing your future research only in open-access journals?

  2. ravenm

    Professor Hickie, you say that you were unable to declare your Servier educational/media activities because you they occurred after you started returning proof corrections in February 2011. But in November 2010 you promoted agomelatine (and second-generation antipsychotics) for early-onset depression in young people (12-25) at a Servier Depression Masterclass. Furthermore, you could probably have added a declaration about your April 2011 activities (including a Servier briefing ‘Professor Hickie said clinical trials have shown Valdoxan can ease depressive symptoms while also improving sleep….’) before publication, particularly given that they must have been arranged in advance. Jon Jureidini and I finalised our proof of our letter 10 days before publication.

  3. PJHyslop

    Vested interests? The only vested interests in mental health is the pharmaceutical industry -the same industry which pays Prof Hickie so handsomely. What difference does it make how the editor criticses a contributer’s research (Twitter or otherwise)? I think the fact he has taken the time to do so publicly means he would be pretty confident of these criticisms.

  4. simon.chapman

    There may be a few people who are so opposed to pharmaceuticals of any sort that they oppose them for arcane reasons like Scientology dogma. Most of the rest of us are occasionally and sometimes daily glad about an awful lot in modern pharmacology. My hypertension has been well in check for years thanks to a drug I take which has never caused me problems. Last week I cracked a rib and was very glad to get access to strong analgesia. My daughter is in Uganda, and I’m very thankful to the pharmaceutical industry and the scientists who work inside it and outside for it, that she is able to use the latest anti-malarials that have developed because of research. In the same way that I pay any private producer for anything I buy from them, I don’t mind paying for these drugs, but am glad that I live in a country where their price can be subsidised.

    I also agree that the pharmaceutical industry often does its best to medicalise everyday problems that don’t require drug solutions, that it sometimes engages in reprehensible pricing policy, and that there have been many sordid episodes of unethical conduct in that industry (in which it is hardly unique). But in balance, I’m very pleased that the pharmaceutical industry is there and should I ever have a mental health problem where the best evidence suggested I might benefit from medicating it, I would be pleased to do that as well.

    So what are we to make of medical specialists like Ian Hickie who want their patients to have access to drugs that might benefit them, and who engage in research with the companies who produce the drugs? Hickie stands accused by some of having “vested interests”. He readily agrees that he does and says he has fully declared those interests. Is the argument of his critics that University clinical professors should not engage in research? Who should pay for it then? Is is that pharmaceutical companies should not do research, or that they should do it entirely internally? Or that no one working in a specialty area of medicine should ever engage with the pharmaceutical industry? Or that they should only do it gratis? If the former, who then should engage in such research? Should kidney specialists do clinical trials in psychiatry? Cancer specialists in dentistry? There does not seem much sense in that.

    And why should anyone be expected to work for a private for-profit company as if they were some sort of charity which should not pay for the time and effort put in that may one day bring riches to the company? That is not behaviour we expect of anyone in any other circumstance.

    There is a large research literature that is taken to mean that he who pays the piper tends to call the tune. This work shows that industry sponsored trials tend to produce results which favour the sponsors’ interests. Sometimes this occurs through fraud, or through the prism of money-coloured glasses which blind researchers to certain research questions or interpretations of data that those without the glasses can see. But one very important reason for this is that companies rarely get a drug all the way through to the stage of human trials if they by then do not already have many reasons for thinking that it is is highly likely to work.

    So what is Ian Hickie actually accused of by his critics? It would be interesting to do random checks of the home medicine cabinets of those who are howling him down. If their cupboards were not bare, are they anything more than duplicitous free-riders on the work of researchers who helped develop and test the products that they privately consume when the need arises?

    Lest us hold arc lights of scientific skepticism against all research, public and private. Let ‘s publicly shame scientists who commit fraud. Let’s warn researchers of how some of their colleagues are little more than academic marketing arms for useless or me-too duplicative products. But let us admire and respect those researchers who strive to improve health and save lives through he development of important vaccines, drugs and other therapeutics.

  5. givetogetback

    It’s a bit of a smash and grab campaign with mental health funding. As usual doctors/psychiatrists are positioning themselves most forcefully in the front row in this fledgling area of the health budget. Their legitimacy is granted by way of the dominance of the medical model in understanding and treating mental illness. This is in spite of the fact that many criticise this model for it’s superficiality and often short lived benefits.
    It is dispiriting that almost every scheme developed has adopted this medical model in an unquestioning manner. For example the better access scheme was developed with the GP’s placed in a position of “gatekeeper”, responsible for diagnosis and initial referral to allied health services treatment. The fees they were paid for this service were recently revised, following research that highlighted just how much of the budget was being eaten up before a patient received a scintilla of treatment. There are perhaps questions around GP’s abilities to adequately diagnose and make decisions around effective treatments for patients and whether other mental health professionals are better placed to provide this (e.g. registered psychiatric nurses, psychologists and social workers).
    Anti depressant prescription is still the front line for treatment with depression. This is despite the fact that assessment may be insufficient due to insufficient training and expertise or time available in their practice (in a significant number of cases a single medical consultation lasting 10-15 minutes is the basis for prescribing anti depressant medication). There is increasing evidence that provides qualifications on the effectiveness of pharmacological interventions for mental health. Moreover, there are increased warnings about negative unintended effects (such as increased suicidal ideation and behaviour).
    In public discussion of mental health spending there is little of equivocation over the effectiveness of these treatments. It would seem a sell is taking place with the less appealing aspects hidden from view. The relationship between the prescription of pharmacological treatments and pharmacological corporations is an issue worthy of further scrutiny in all aspects of public medicine. It deserves further scrutiny in mental health due to the more tenuous relationship between mental illness and pharmacological treatment.

  6. Ben Harris-Roxas

    I’ve been sorry to observe a series of unfair and unnecessarily nasty attacks on you and Professor McGorry online over the past year or so. While I agree with almost all your points I’d like to argue against your characterisation of Twitter as the partial culprit. Social media might allow bad behaviour but it’s not the cause of it. Engage with social media; use it to spread your message. There are more of us on Twitter who support your work and who are sympathetic to your views than you probably realise.

  7. Murf

    As a [South Australian] Twitter user and as a researcher who has found it very difficult to get articles published in The Lancet I would like to say that I also have largely supported Prof Hickie in the broad aspect of the debate over the agomelatine article. My only misgivings came when I discovered that he had given the support to Servier/agomelatine in workshops after the acceptance of The Lancet article. I still believe that Prof Hickie hasn’t benefited in person from payments from Servier based on my experience of drug company involvement in treatment trials, but I think it was a lapse in judgment of the journal and/or Prof Hickie, not to mention every instance of connections with Servier in the notes on the published article. My opinions about the referencing or efficacy ascribed to agomelatine, any lack of clinical comparison and other issues seem irrelevant to the debate over C of I allegations, and merely academic.
    In future it might be useful for journals and/or drug companies and authors to explain exactly what a company sponsors and where authors have NOT received monetary or in-kind rewards for using their products. I recall mentioning at some time that Servier had provided the drugs and compounded the placebo for a trial, but did not say explicitly that they had not provided other assistance (which they had not); [Stern, Walker, Sawyer,Oades,Badcock & Spence, 1990]. Maybe the convention needs to adapt to modern demands.
    The Twittering of The Lancet’s editor seems rather odd to me and should be dealt with by the journal in my opinion.

  8. Darren Stones

    Now Ian, just get off your high horse for a minute. You’re in the political arena, so expect commentary. The world is not black and white, so I suggest you move into the grey area.

    From a consumer perspective, your views are becoming less respected. Some of your high profile colleagues are also being questioned and I think fairly, too. See, there’s big bikkies at stake, and you are doing your utmost to get your slice of the action, just like your comrades.

    Consider putting the consumers into the middle, and then attaching yourself to them. Quite simply, you come across like a pompous ass.

  9. Ben Mullings

    It is really quite disappointing to see even more remarks from Professor Ian Hickie that are disparaging to those who are critical of some of his previous work and statements. Negative and undermining comments directed at both the editor of The Lancet, and indeed The Lancet itself, is unfortunately just more of the same style over-zealous and negative commentary that people out there are expressing concern about.

    Can Professor Ian Hickie please demonstrate that offering just 10 sessions of psychological treatment will produce lasting recovery in the treatment of common mental health conditions?

    This is the main question that patients and the general community are wondering about, given his statement at the Senate Inquiry that “people who come to the end of the 10 sessions need something more…they do not just need more of the same,” and that “going beyond 10 sessions should have been and should remain exceptional.” If Hickie cannot support that claim, then I ask that Hickie let that fact be widely known so that our policy makers understand that it was not a claim based on firm research or scientific consensus.

    There is no amount of harsh commentary that Hickie (or anyone else) can make about the people raising these criticisms that will answer that question, so let’s please get on with addressing the the content of criticism properly instead of using media to demonise the critics.

  10. alisonrixon

    This debate was addressed by Bruno Latour in 2003 – “While we spent years trying to detect the real prejudices hidden behind the appearance of objective statements, do we now have to reveal the real objective and incontrovertible facts hidden behind the illusion of prejudices?”

    Critique has evolved to presume that all science is a fraud corrupted by bias and any attempt to deny these allegations is dismissed as naive. Science is based upon the replication of results. If Prof Hickies’ results can’t be replicated by other researchers, then they will be rejected. The paper was peer reviewed to try to make the process as objective as possible.

    Research is paid for by commercial interests- if you aren’t happy with this then start fundraising or lobbying government. Prof Hickie has pointed out that the editor of the Lancet has a possible conflict of interest and that is equally true. I am personally grateful for drugs developed to treat depression, I presume by Big Pharma. I would not be alive today without one particular anti-depression drug. A friend hung herself after suffering depression for many years, but refusing any drug treatment. She left three small children, one of whom was only four years old. But I suppose some people will say I’m just being naive.