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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study Nicola Filippini, Claire Sexton, Abda Mahmood, Peggy Fooks, et al. 357:doi 10.1136/bmj.j2353

New concepts about so-called common sense are always challenging, not disregarding that it´s true observational studies likely provide the best available evidence or “the identification of harms when randomised controlled trials would seem unethical or impractical”(1).
In statistical hypothesis testing, a type I error is the incorrect rejection of a true null hypothesis. so is a "false positive", while a type II error is incorrectly retaining a false null hypothesis, i.e, a "false negative".
Simply put, a type I error is the false detection of an effect that is not present, while a type II error is the failure to detect an effect that is present. Emphasizing that in this study authored by Topiwala et al, because of the small number of subjects involved, and the always large 95% confidence intervals of alcohol-related brain health effects presented; a type 1 statistical error(2), could have happened, namely when using proxies or surrogates markers of diseases, in the occasions where exist today all kinds of non-alcoholic beverages for testing of pragmatic randomized clinical trials,(3).

Table of error types(2).

Table of error types Null hypothesis (H0) is
True False
Decision About Null Hypothesis (H0) Reject Type I error
(False Positive) Correct inference
(True Positive)
Fail to reject Correct inference
(True Negative) Type II error
(False Negative)

REFERENCES:

1. S. Barton. Which clinical studies provide the best evidence?
The best RCT still trumps the best observational study. BMJ. 2000 Jul 29; 321(7256): 255–256.

2. Sheskin, David (2004). Handbook of Parametric and Nonparametric Statistical Procedures. CRC Press. p. 54. ISBN 1584884401.

3. Laura A. Young, MD, PhD; John B. Buse, MD, PhD; Mark A. Weaver, PhD; Maihan B., et al, for the Monitor Trial Group . Glucose Self-Monitoring in Non–Insulin-Treated Patients With Type 2 Diabetes in Primary Care Settings. A Randomized Trial. JAMA Intern Med. doi:10.1001/jamainternmed.2017.1233 Published online June 10, 2017.

Competing interests: No competing interests

16 June 2017
Jose Mario Franco de Oliveira
Associate Professor of Medicine.
Claudia Sabatini. Cognitive Behauviour Psychologyst.
Department of Medicine. Universidade Federal Fluminense, Niteroi, Rio de Janeiro, RJ, Brazil
Rua Senador Vergueiro #2 apt. 202. Zip Code: 22230-001
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19
Re: Stress at work Thomas Despréaux, Olivier Saint-Lary, Florence Danzin, Alexis Descatha. 357:doi 10.1136/bmj.j2489

It is very welcome to see a month of BMJ issues highlighting the importance of access to specialist Occupational Health Advice in editorials (1), rapid responses (2,3), News (4) and this week in the “10 minute consultation”(5).

In this latest issue, Despereux et al describe Robert Karasek’s classic triad of demands, control and support imbalance (6) in a French executive who presents to his GP with physical symptoms. As clinicians, the authors begin with a welcome focus on the origin and relevance of patient’s symptoms. Encouragingly their enquiry expands to include Bernardino Ramazzini’s tenet - ask the question “What is your occupation;” this is often missing from patient records worldwide (7). The authors helpfully provide a comprehensive assessment of the occupational antecedents of mental illness arising from adverse workplace context (poor interpersonal relationships, lack of recognition) and content (increasing workload, and decreased control over work organisation).

What is not clear is how they envisage the UK GP integrating this assessment in an already stretched “10 minute” consultation, let alone addressing the underlying drivers of stress and work. French employees have access to Occupational Health services regardless of company size, making it appropriate for the authors close with the question - “In difficult cases, do you work in collaboration with mental health professionals and occupational health professionals?” As Torrance and I highlighted in our recent editorial (1), such a model for clinicians to refer complex cases to occupational physicians does not exist for most UK employees.

Our role, invisible and inaccessible to many involves seamlessly working the space between employee, primary care professional, and employer for mutually beneficial outcomes. In a country urgently addressing issues of competitiveness in a post-Brexit world, the UK urgently needs to invest in occupational medicine if we are to see returns measured in healthier workers and a healthy economy.

References:
1. Torrance, I and Heron R. Occupational health should be part of the NHS BMJ 2017;357:j2334
2. Nicholson, P. Rapid response. http://www.bmj.com/content/357/bmj.j2334/rr
3. Aston, IR. Rapid response http://www.bmj.com/content/357/bmj.j2334/rr-0
4. Limb, M. Senior NHS doctors face huge burden of work related illness, researchers find BMJ 2017;357:j2603 doi: 10.1136/bmj.j2603
5. Despréaux, T, Saint-Lary, O, Danzin, F and Descatha, A. Stress at work. BMJ 2017;357:j2489
6. Karasek, RA. Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Redesign. Administrative Science Quarterly Vol. 24, No. 2 (Jun., 1979), pp. 285-308
7. Ramazzini, B. De Morbis Artificum Diatriba, 1713. Padua
8. Politi BJ1, Arena VC, Schwerha J, Sussman N. Occupational medical history taking: how are today's physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center. J Occup Environ Med. 2004 Jun;46(6):550-5.

Competing interests: No competing interests

16 June 2017
Richard JL Heron
Occupational Physician
President, Faculty of Occupationl Medicine
69-73 Theobalds Rd, London WC1X 8TA
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16
Re: Assisted dying for healthy older people: a step too far? Els van Wijngaarden, Ab Klink, Carlo Leget, Anne-Mei The. 357:doi 10.1136/bmj.j2298

I used 'life complete' in a different way when, after the untimely death from cancer of my brother-in-law, I wrote for his wife, on his behalf, the following lines after a well known unknown poet. He loved sailing and was loved by everyone.

As you held my hand

Do not stand at my grave and weep,
I am not there - I do not sleep.
Grounded fast in silt and sand,
I blessed you as you held my hand.

But came high tide I had to weigh,
To catch the wind and sail away.
Freed from razor rocks at last,
I hoist bright colours to the mast.

Flying fish skim and soar,
As I leave this jagged shore.
With steely voice I hail the fleet,
Saddened not - my life complete.

Forever bronzed on cobalt blue,
Gone - but never far from you.
I sail the line that loops the poles,
I sail the loop that links our souls.

Although intended as private verse, after reading this article I have decided to share it.

Competing interests: No competing interests

16 June 2017
Mark W Davies
consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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17
Re: NICE approves trastuzumab emtansine after deal with drug company Zosia Kmietowicz. 357:doi 10.1136/bmj.j2930

Anyhow, it is well established that most old [1][4] or novel [2][3] chemotherapeutic agents prolong patients' survival for only 3 months.
Such poor cancer drug efficacy/survival benefit results should be rendered known to the public and to those journalists who write promotional articles on the "miraculous cures" of these agents.
References
[1] http://www.bmj.com/content/355/bmj.i5792
[2] http://www.bmj.com/content/356/bmj.j30
[3] http://www.bmj.com/content/357/bmj.j2129
[4] https://www.ncbi.nlm.nih.gov/pubmed/15630849

Competing interests: No competing interests

16 June 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: NICE approves trastuzumab emtansine after deal with drug company Zosia Kmietowicz. 357:doi 10.1136/bmj.j2930

The decision by the NHS to approve trastuzumab emtansine, which will add an average of six months of life to about 1,000 people with terminal breast cancer, has been praised by campaigners as a "monumental" U-turn. NHS England chief executive Simon Stevens noted that “both patients and taxpayers are getting a good deal".

However, at a cost of £166,000 per QALY, the price tag of this drug, raises questions on the ever-expanding costs of health care. Controlling costs in a nationalised system of health care funding is difficult because normal market forces that help establish a reasonable price for products are disabled: normally, consumers would simply not buy a product if they do not deem it worth their money. Things become complicated when the interests of the beneficiary of a product (the patient) diverge from those of the buyer (in this case, society). Stevens’ remarks notwithstanding, it is always difficult to put a price tag on your health, but it is nigh impossible to put it on someone else’s. So far, the result of this disconnect has been ever increasing drug prices, especially for drugs used to treat rare diseases. It is clear that from a societal standpoint, a continued rise is unsustainable.

I propose to restore the connection between price and actual value of a novel treatment by putting the decision to purchase back in the hands of the patient. Rather than offering the drug for free, I suggest that patients are offered the cost price of the drug in cash together with a prescription. Patients will then be able to decide for themselves if the expected benefit is worth the money. If not, they are free to spend the money as they wish.

At face value, such a proposition may appear outrageous, as it seems to amount to rewarding people with large amounts of money simply for having a certain disease. However, this arrangement does not change the basic tenets of the current system: patients will continue to have access to treatment for their disease and the cost to society will remain the same, at least in the short term. The only addition is that this proposal provides the patient the power to choose, thereby providing the health care provider information on the actual value of a drug. This information can be used to drive down prices in the long term.

Even without further intervention, such a system will likely affect drug prices as drug manufacturers are bound to lower their prices when very few patients decide to buy the drug at its current price. It will probably be even more effective to stipulate at the introduction of a novel therapeutic that its price will be modified by a certain amount that depends on the percentage of patients buying the drug. E.g., prices will be lowered if fewer than 50% of patients buy the drug and prices will be allowed to rise a pre-determined amount if the drug is bought by more than 90% of patients. Given the extreme prices currently seen for some treatments, manufactures will not be likely to embrace such a proposal as they fear that it will affect their profits. However, even drug manufacturers will benefit from this system in the long term as it will help to create a fair and level playing field for all producers and provide insight in the real value of their products.

In some cases, the financial gains provided to a small number of people based on rather arbitrary criteria may constitute a perverse incentive to falsely or wrongly diagnose certain diseases. However, I feel that this risk is limited for many diseases with clear diagnostic criteria. This holds especially true in the case of patients with terminal, HER2 positive metastatic breast cancer.

Competing interests: No competing interests

16 June 2017
Martijn R. Tannemaat
Neurologist/Clinical Neurophysiologist
Leiden University Medical Center
Albinusdreef 2, 2300RC Leiden, the Netherlands
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Re: David Oliver: How can we plan for old age if we won’t discuss it honestly? David Oliver. 357:doi 10.1136/bmj.j2759

Many of the elderly might like to have discussions about the implications of ageing and declining health including their mortality. I am one of those elderly who wish to maximise my present opportunities but this also means taking likely quality lifespan into account before interventions. I see discussion about that as outside the competence of many doctors, and medical training scarcely prepares for discussion on personal philosophies. Responses can be judgemental whilst comparing prognosis to the length of a piece of string is outdated and patronising. Assuming I could arrange a GP appointment, this is likely to be very targeted and too short to discuss wider implications. Doctors themselves often seem to find talking about ageing and dying – in the surgery and with their own families – very difficult. Some even refuse to engage in discussion about advance decisions. At hospital the attitude is often that if any intervention can be done then it should be done - the elderly being particularly vulnerable to avoid accusations of ageism.

On listening to an intensivist a few months ago it seemed that ITU care of the elderly now mirrors that of the newborn needing it. Families can have very mixed motives whilst all parties are subject to social pressures and taboos. Some older patients and their families doubtless cope with dying by denial and we need to think carefully before challenging this. As for being a burden – of course many of us may well be, either on ourselves or others. We may need help in coming to terms with this but the reality will be there. So who is the real ostrich then?

Along with anecdotally extolling the glories of growing old, dying also features strongly in the media as a subject in discussion and obituary columns, a feature of many local and national papers. The media and public showed considerable interest in the assisted dying for the terminally ill (ADTI) debate, with widespread public support for the Bill. Even recent issues of Private Eye have had a full length (and excellent) article on ADTI, another on Death Cafes and 1 or 2 relevant (if slightly “sick”) cartoons. MDMD (My Death My Decision) has a particular emphasis on old age and a rapidly growing membership. Some elderly will have contingency plans, in line with the suggestion of David Oliver that the way to avoid ageing is to stop living: not something to discuss with a GP in 10 minutes. For many of the elderly – and some of us were born before the last war – there is an awareness, reinforced regularly by the death of contemporaries, of death and decline that perhaps exceeds that of many doctors. We may even wonder where we are in the queue but do not see it as an essentially medical problem.

Competing interests: No competing interests

16 June 2017
Simon Kenwright
Rtd Physician
None
Stowting, Kent TN25 6BD
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Re: Cuts to addiction services are a false economy Colin Drummond. 357:doi 10.1136/bmj.j2704

Colin Drummond is spot on adding his voice to many others deprecating cuts and repeated changes to drug addiction services resulting in scandalous increases in (preventable) mortality and morbidity in this always neglected group of our patients.

The Contribution of Secondary Care
There is no evidence to show that investment in such services in Secondary care in the first part of this century contributed to 'a long track record of success since the 2000s'. During this time secondary care drug clinics were practising (and still do , I believe) what came to be termed 'revolving door' care where the majority of patients failed to comply with the 'rules' such as losing their drugs (easily done when sleeping rough or living in a hostel), 'using on top', buying other patient's drugs, stealing the same, etc. resulting in instant discharge from the service. 'Success' was measured in months not years so even the few patients lasting through the honeymoon period seemed to be successfully treated. Detoxification - mostly for drugs and occasionally alcohol - was and is highly unsuccessful with many patients discharging themselves before the end of treatment (or being forcibly discharged for misdemeanour) and many relapsed post discharge often due to poor follow-up.

The Service Patients Need
In order to prescribe services suitable for drug addicts we need to be aware of the aims behind the idea of 'harm reduction'.

1) Replacement helps stop or reduce drug use and dangerous practice. Methadone replacement must be at least adequate to prevent 'using on top' so there should be no standard idea of a maximum dose (often set at 60mg) some patients will need more.

2) Poor housing, poverty and social conditions an general instability in life mitigate against patients controlling their addiction. Remedy of these help addict rehabilitation

3) Many drug addicts have dual diagnosis(es) of mental illness. Access to ordinary psychiatrists must not be severely limited as it always has been. A question I have always wanted to ask is 'why the addiction psychiatrists can't deal with mental illness as well?'

4) The majority of drug addicts start hard drugs young - around 14 years old. Services to this age group are already inadequate and drug addiction is not in their remit.

5) The majority of drug addicts have very poor childhood history with parental loss, separation, broken homes, and abuse - sexual, physical, mental and deprivation. Their parents are frequently alcoholics, addicts and poor having suffered the same experiences and visiting these on their children. Dealing with each generation and meeting their multiple needs will reduce addiction problems.

6) Addicts' physical illnesses are often related to their addiction. Services must respond to and treat these (injection site infections, Respiratory infections, Deep Vein Thrombosis etc.) immediately or referred to specialist services (e.g. Hepatology , Dental services etc)

7) Addicts have low immunity to illness and high risk of sexually transmitted disease. Prevention must be given even more priority than that used for the non-addict population.

A GP Addiction Service
In my General practice between 2000 and 2008 we looked after over 200 drug addicts and had no drug related deaths during this time . Most addicts were seen weekly especially injecting users and those with other problems mentioned above.

We operated on the principle "never give up on an addict" so we never did. We attended to their wounds, infections, prevention including smears and vaccinations. We listened to them, sympathised, and empathised but also often suggested alternative ways they could deal with a particular problem. We measured our success in the patient number of years in treatment and the amount of time patient were not 'using' i.e. at risk of harm. Those coming off drugs were fairly few but the cure often sustained over time. We are sure we saved many lives and made a huge difference to our addicts and the lives of their families. We were outraged and saddened when the local health authority took away our service on the grounds that they did not like our model of care.

In my view addiction is a multifaceted problem that will not be solved by increasing the number of specialist addiction psychiatrists alone. Those specialists need to change their attitudes and work closely with other services sharing expertise and imparting their knowledge to the grass roots services. Addicts mostly need basic not specialist stuff.

Competing interests: No competing interests

16 June 2017
Roger Weeks
retired GP
Medical Intelligency Limited
Surbiton
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55
Re: Older patients should take PPIs to cut risk of bleed from aspirin, study says Susan Mayor. 357:doi 10.1136/bmj.j2865

The recommendation that older patients should take PPIS with aspirin (1) should be hedged in by the following caveats:

(I) Although the addition of a PPI to low dose aspirin (75-325 mg/day) significantly (p=0.0007) reduces the incidence of gastric and duodenal ulceration (2), small bowel ulceration attributable to nonsteroidal anti-inflammatory drugs (exemplified by aspirin) may still occur despite coprescription of PPIs (3).

(ii) PPIs also come with their own "baggage", which includes hypomagnesaemia, sometimes along with hypocalaceamia and hypokalaemia, the "triad" reported in two patients aged 78 and 81, respectively (4). A systematic review of the medical literature also identified 36 cases (mean age 67.4) of PPI-related hypomagnesaemia during the period 2006 to 2011. The time elapsed between the start of PPI use and hypomagnessemia ranged from 2 weeks to 13 years (mean duration 5.5 years) (5). Paroxysmal ventricular fibrillation may be an occasional, outcome of hypomagnesaemia(6), as may be the occasional occurrence of seizures(7). PPIs are also incriminated in the development of acute interstitial nephritis (8). The latter may add insult to injury in those elderly patients who already have chronic kidney disease characterised by glomerular filtration rate < 60 ml/min (abbreviated Modification of Diet in Renal Disease formula). In those patients PPIs may be associated with significantly (P=0.04) lower serum magnesium levels than in non users, when an analysis is made in patients of mean age 84, and adjustment is made for diuretic use (9). Although the relation between PPI use and Cl difficile infection remains controversial, one observation is that PPI use remains rampant, and its inappropriate use should be reduced regardless of its effect on C difficile infection (10). The corollary is that inappropriate use of aspirin (exemplified by its use in nonvalvular atrial fibrillation) remains rampant, and its inappropriate use should be reduced so as to mitigate the risk of potentially harmful use of PPIs.

References
(1) Older patients should take PPIs to cut risk of bleeding from aspirin study says. BMJ 2017;357:j2865
(2) Yeomans N et al. Efficacy of esmeprazole (20 mg once daily) for reducing the risk of gastroduodenal,ulcers associated with continuous use of low-dose aspirin. Am J Gastroenterol 2008;103:2465-2473
(3) Goldstein JL., Eisen GM., Lewis B., Gralnek IM., et al. Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole and placebo. Clin Gastroenterol Hepatol 2005;3:133-141
(4) Shabajee N., Lamb EJ., Sturgess I., Sumathipala RW. Omeprazole and refractory hypomagnesaemia. BMJ 2008;337:173-175
(5) Hess MW., Hoenderop JGJ., Bindels RJM., Drenth JPH. Systematic review: hypomagnesaemia induced by proton pump inhibition. Alimnt Pharmacol Ther 2012;36:405-413
(6) Loeb HS., Pietras RJ., Gunnar RM., Tobin JR. Paroxysmal ventricular fibrillation in two patients with hypomagnesemia. Circulation 1968;37:210-215
(7) Arulanantham N., Anderson M., Gittoes N., Ferner R. A 63 year old man with hypomagnesaemia and seizures. Clinical Medicine 2011;11:591-593
(8) Geeva singa N., Coleman PL., Webster AC Roger SD. Proton pump inhibitors and acute interstitial nephritis. Clinical Gastroenterology and Hepatology 2016;4:597-604
(9) Sumakadas D., McMurdo MET., Habicht D. Proton opump inhibitors are associated with lower magnesium levels in older people with chronic kidney disease. Jouranl of the American Geriatric Society 2012;60:392-393
(10) Hughes K., Lalikian KA., Schwartz J., Turner RB. Are proton poump inhibitors associated with an increased risk of Clostritium Difficile infection after considering confounding varaiables. J Hospital Infection 2017;95:445-446

Competing interests: No competing interests

16 June 2017
Oscar M Jolobe
retired geriatrician
manchester medical society
simon building brunswick street manchester M13 9PL
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71
Re: The safety of antidepressants in pregnancy Lars Henning Pedersen. 357:doi 10.1136/bmj.j2544

Whose interests were served by this recent BMJ editorial? (1).The title was oxymoronic and misleading. The article’s opening claim that “the safety of antidepressants in pregnancy is controversial.” is false. The history of the investigation of antidepressant drug safety in pregnancy is characterized by unacceptable delay. The known long list of frequent and documented serious adverse effects means we cannot continue to overlook harm.(2-4) Pedersen’s bottom line - “pregnant women with severe depression need effective treatment that will in most cases include antidepressants” - cited a review(5) whose authors corrected their mistake when challenged, stating: “we fully agree that psychological treatments should be offered for depression of all severity.”(6,7) Cognitive behavioural therapy (CBT) and antidepressants are similarly effective against major depression but CBT has fewer adverse effects, so it is unethical not to offer CBT first.(8) Moreover, patients prefer psychotherapy.(9) Even the supposed drug efficacy deserves re-evaluation: there are no adequate and well-controlled studies in pregnant women. (10) This must be addressed given that numerous antidepressant trials have misrepresented findings (11,12), and efficacy is not observed in several specific populations (i.e. children and adolescents, chronic heart failure, alcohol use disorders).

“First do not harm” still resonates in the liberal pill era. Drugs should not be the first option for women of childbearing age given teratogenicity can occur before pregnancy is confirmed and signed consent should be obtained. To counter over-use, it might be be wise to restrict the initial antidepressant prescription in girls and women of childbearing age to specialists only.(13).

1 Pedersen LH. The safety of antidepressants in pregnancy BMJ 2017;357:j2544

2 Hayes RM, Wu P, Shelton RC et al. Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies. Am J Obstet Gynecol 2012;207:49.e1-9.

3 Hanley GE, Smolina K, Mintzes B, Oberlander TF, Morgan SG. Postpartum hemorrhage and use of serotonin reuptake inhibitor antidepressants in pregnancy. Obstet Gynecol 2016;127:553-61.

4 Bérard A, Zhao JP, Sheehy O. Antidepressant use during pregnancy and the risk of major congenital malformations in a cohort of depressed pregnant women: an updated analysis of the Quebec Pregnancy Cohort. BMJ Open 2017;7:e013372.

5 Vigod SN, Wilson CA, Howard LM. Depression in pregnancy. BMJ 2016;357:i1547.

6 Braillon A, Bewley S. Paucity of data on the safety of drugs for treating depression in pregnancy. BMJ 2016;353:i2582.

7 Vigod SN, Wilson CA, Howard LM. Authors' reply to Braillon and Bewley. BMJ 2016;353:i2583.

8 Gartlehner G, Gaynes BN, Amick HR, et al. Comparative benefits and harms of antidepressant, psychological, complementary, and exercise treatments for major depression: An evidence report for a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;164:331-41.

9 McHugh RK, Whitton SW,Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry 2013;7:595-602.

10 O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU Primary care screening for and treatment of depression in and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016 ;315:388-406.

11 Le Noury J, Nardo JM, Healy D et al. Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ2015 16;351:h4320.

12 Jureidini JN, Amsterdam JD, McHenry LB. The citalopram CIT-MD-18 pediatric depression trial: Deconstruction of medical ghostwriting, data mischaracterisation and academic malfeasance. Int J Risk Saf Med 2016;28:33-43.

13 Braithwaite R. Evidence suggests massive overdiagnosis and, by extrapolation, overprescription of antidepressants. BMJ 2014;348:g1436.

Competing interests: No competing interests

16 June 2017
Alain Braillon
senior consultant
Susan Bewley (Women's Health Academic Center, Kings College London, London, United Kingdom)
University Hospital. 80000 Amiens. France
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69
Re: Bullying in NHS must be “called out,” says head of NHS Improvement Tom Moberly. 357:doi 10.1136/bmj.j2923

Editor

I don't want to make this personal about NHS Improvement Chief Executive, Jim Mackey, who was a very well respected hospital chief executive in a trust that scored better than most on staff morale and engagement and who always strikes me as someone who would feel more at home going back to such a role rather than heading up a national regulator.

However, what his speech failed to acknowledge was the "Elephant in the Room" that the bullying culture in the NHS starts right at the top from the Department of Health and from NHS England, NHS Improvement and the Care Quality Commission. I don't say for a moment that this is their only modus operandi, nor that there aren't some very well intentioned people in those roles.

However, time and again, we have seen instances of huge pressure around targets, finances and news management placed onto already struggling NHS organisations. We have also seen inspection reports that were damning, with the regulator sometimes appearing to relish the media spotlight gained from talking tough. The behaviour of the Secretary of State in fomenting and perpetuating a completely avoidable stand off with junior doctors was reprehensible and NHS Employers sadly colluded in this.

In an NHS that is already struggling with a huge funding shortfall, rising demand and a workforce crisis, the top down "targets and terror" culture from central bodies wanting to maintain "grip" and in turn stay the right side of government ministers is singularly unhelpful. It even extended to Strategic Transformation Plans being told to promise unevidenced redutions in activity and unachievable savings plans in their iniital communications; or acute providers in winter being told to play down bad news about the urgent care crisis.

In such an environment, it's no wonder that we struggle to attract or keep senior NHS managers in post for long enough to provide stability. Nor that many of them pass the pressure they are subject to down the line to clinical teams, further affecting their morale and on occasion making them feel bullied.

One need only see the percentage of comments on the Health Service Journal message boards which remain anonymous to see how worried many NHS managers are about speaking up.

As Mr Mackey is moving on soon and therefore able to speak his mind, it's a shame he didn't use his speech to point out that national NHS leadership from Whitehall downwards plays a huge part in the bullying culture and needs to do more to support rather than blame or pressurise NHS providers and commissioners.

David Oliver

Competing interests: No competing interests

16 June 2017
David Oliver
Consultant Physician
NHS
Berkshire
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