WDDTY invents advice from researchers on antidepressant use in pregnancy and Autism

Two major drug groups could cause autism
Autism is a fertile hunting ground for quacks and cranks. Pseudoscience is rampant. It’s hugely draining for parents, there is precious little anyone can do about it, and the causes are unknown. It’s notorious as the foundation of Andrew Wakefield’s fraudulent MMR studies, and quack treatments such as chelation therapy and bleach drinking cross the line into child abuse. Parents are driven to horrific and desperate lengths, often by the very cranks who claim to support them.

The SCAM community (naturally) tries to pin the blame on the bogeyman du jour: vaccines, of course, antibiotics, mercury, fluoride in the water, electrosensitivity – and here, antidepressants.

There are three truly evil aspects of this story. First, it screams about a threefold increase in risk, when actually it goes from 0.6% to 1.3% . Second, it screams cause when the study referenced explicitly repudiates this, as well it should – a case control study has no way of telling if, for example, there is a genetic cause which is a cofactor in both maternal depression and autism. Third, and worst by far, it lays a burden of guilt at the feet of the mothers, without any good evidence to back this.

There’s no doubt that the less medication a pregnant mother uses, the better. On the other hand the dramatic effects of depression are well documented. There is always  a balance of risk and benefit in any effective treatment (whatever the peddlers of natural woo tell you to the contrary).  WDDTY cynically exploit and exaggerate the risks, and ignore the benefits, in order to serve their own agenda – a case this eloquent blog post makes very clearly.

 

Reblogged from NurtureMyBaby with permission

“What Doctors Don’t Tell You” is a magazine that apparently, for the princely sum of £3.95 “aims to meet the demand of those seeking information about alternatives to conventional medicine.”

In my opinion this should actually read misinformation. And as GP, Margaret McCartney, put it “The only ethical way I can see of selling it is if it is kept behind the counter in a plastic bag, with a label saying the contents are dangerous.”

Yet supermarkets continue to stock it (apart from Waitrose), despite many people making them aware of issues with its content.

If you’ve not heard of this magazine before there are many, many blog posts about the misinformation presented in this magazine. On cancer and chemotherapy. HIV/AIDSHomeopathyThe HPV vaccineMMR.

There’s a master list of posts over on Josephine Jones’s blog too, as well as a whole blog dedicated solely to highlighting the issues with this magazine.

autism-antidepressantsIn this post I want to talk specifically about the article titled “Two major drug groups could cause autism” found on page 17 of the November edition that states:

“Women who take certain prescription drugs while pregnant are increasing the chances of Autism in their child”

The drugs that the magazine “reports” on are antidepressants and Epilim. I wanted to take a closer look at the claims made about antidepressants. I tend to get my knickers in a twist about flippant pill shaming so any hint of that and my interest is piqued.

I checked the reference that the magazine points you to and I don’t think it backs up what is written.

The magazine tells you:

“All antidepressants, including the newer generation of SSRIs, triple the chances of the unborn child developing autism”

There’s a few issues with this statement in my eyes.

Absolute risk versus relative risk

“Triples the chances” Crikey. Sounds dramatic doesn’t it. Well first off the “triples” figure is not backed up by the results in the paper. We can look at that in a bit more detail later.

But a big issue I have with this is that WDDTY have done that thing, where, in order to make a story sound a bit more exciting, a bit more headline grabbing, they have reported solely on the relative risk.

This seems to happen quite a lot in the media in general, it’s certainly not unique to WDDTY. It’s frequent enough that Cancer Research UK have gone to the trouble of writing a pretty good explanation of the meanings of relative and absolute risks here.

The relative risk tells us:

“how much more, or less, likely the disease is in one group, compared to another.”

When it is reported that the risk is tripled, this could mean that the risk is 20% in one group and 60% in another. Or it could mean the risk is 0.1% in one group and 0.3% in another. The figures I’ve given in these examples are known as “absolute risks”

As there is a big difference between a 60% risk and a 0.3% risk, you can see that to solely report on the relative risk with no mention of the actual figures involved ie. the underlying absolute risks does not give the full picture. From looking at the WDDTY article we have no idea what the absolute risks are, nor is the writer clear about the two groups being compared.

I’m no expert, but looking at the actual paper, I tried to work out where this “triple the chances” came from. I’m not entirely sure.

In very (and probably, over-) simple terms, the research took a load of people with autism (cases) and then took a load of people who matched the autism group in terms of sex and age, but did not suffer from autism. This second group is known as the control group. Then they looked at information on the parents of the people in both groups and looked at how many suffered from depression and how many mothers took antidepressants during the pregnancy, including the type of antidepressant.

Then they did lots of clever number crunching. It’s impossible within the scope of this blog post to go into the details of the statistical analysis that was performed. But a key conclusion that they reached is that:

“Any antidepressant use during pregnancy in mothers of cases was 1.3% compared with 0.6% of controls equating to an almost twofold increase in risk of autism spectrum disorder”

So it seems that the figures for the absolute risks in these two groups are rather low and ultimately, when they did all their odds ratio calculations, it showed almost double the risk, not triple. I think reporting on the figures shown above, alongside the relative risk, would have given WDDTY’s article a bit of a different feel.

(It is all a bit tricky, and my understanding of the numbers and the way the study was done means that the above percentages do not relate directly to risks in women that do take antidepressants versus those that don’t – so it is a bit unfair to simply say that they should have quoted these numbers as absolute risks – but I think some context is needed other than just saying “triples” – this all goes to show the really big problems with just taking numbers out of context in the manner that WDDTY have done. I’m sorry if my attempt to clarify the numbers has made matters worse. Perhaps I should delete all of this section and just say – “I think you’ll find it’s a bit more complicated than that”)

That’s not to say that relative risks are unimportant, indeed they are of great importance in decision-making – comparing risk/benefit of one exposure/treatment vs another, but the absolute risks do put them in context, and I feel that context is important.

Sadly, context is frequently missing in WDDTY. (Another example of missing context can be seen in an article on UTIs and antibiotics, where in failing to tell us the actual purpose of the research they cite, WDDTY try and take a figure from the paper and extrapolate it to the general population, thus having us believe that 70% of women can get better from uncomplicated UTIs without antibiotics, when the figure is actually estimated to be 25 – 50%)

To be fair to WDDTY, (I don’t know why I keep bothering to do that) I think I can see where they got the “triples” figure from. I think (from looking at table 4 in the paper) it is from looking at a link between depressed women taking antidepressants and autism in offspring, rather than a link between taking antidepressants and autism in offspring. (Antidepressants can be prescribed for things other than depression, such as neuropathic pain.)

I think this serves to highlight the importance of my earlier question of what two groups are we comparing when we talk about a tripled risk, and it also highlights the general importance of context.

Causality

The paper this article is based on is very cautious about saying that antidepressant use directly causes autism. It says:

“it is not possible to conclude whether the association between antidepressant use and autism spectrum disorder reflects severe depression during pregnancy or is a direct effect of the drug.”

And

“Caution is required before making causal assumptions or clinical decisions based on observational studies”

I don’t think this is reflected in what we see in WDDTY. I think the two statements I’ve already quoted from the magazine infer that autism is caused by the drugs. Here they are again:

“Women who take certain prescription drugs while pregnant are increasing the chances of Autism in their child”

“All antidepressants, including the newer generation of SSRIs, triple the chances of the unborn child developing autism”

Notice that in that first sentence, it’s not even the drugs that WDDTY wants to blame, it’s the women themselves that are increasing the chances by taking the drugs.

No consideration at all that it might be the severity of the depression that could result in an increased risk of Autism and that perhaps treatment might reduce the risk (the researchers even explicitly say this later, as we’ll see, so I’m not sure what WDDTY’s excuse is for failing to mention this.)

Certainly no consideration for the fact that it is not the individual fault of any women that she might end up in a position where taking antidepressants is necessary. Just a straight up blame game, yep, take these drugs and YOU, pregnant lady, are increasing the risk of damaging your unborn child. I can’t put into words how much I’m annoyed by the way WDDTY frames this sentence.

I’m not the only one who sees a problem with how happy WDDTY seem to be to blame pregnant women.SouthwarkBelle has also written about the way WDDTY misrepresent this research.

Perspective

Further reading of the paper offers further perspective on the figures:

“From a public health perspective, if antidepressant use had a causal relation with autism spectrum disorders, it would explain less than 1% of cases”

The actual figure, given elsewhere in the paper is 0.6%. So looking at it this way, not only is “triples” inaccurate, it also appears to be a little alarmist. What would you do if you were a responsible health journalist, would you report on an invented tripled risk or would you report on the 0.6% of cases that would result if antidepressant use did cause autism?

(I think ideally, you might write more than 3 paragraphs, so that you can go into a little more depth and provide context)

Also of relevance is this:

“All associations were higher in cases of autism without intellectual disability, there being no evidence of an increased risk of autism with intellectual disability.”

Once again if WDDTY looked closely at the study and were careful to point out this detail….well it paints the research in a different light doesn’t it? An association between anti-depressants and autism was found but only with autism without an intellectual disability. Less alarmist, for sure, not really WDDTY’s style.

“Seek out non-drug therapies, say researchers”

Now we move onto what I find to be the worst part of the article. Here is the full sentence I’m talking about:

“So women who suffer from depression during pregnancy should seek out non-drug therapies, say researchers from the University of Bristol”

Gosh. If I was pregnant and had decided to take or stay on antidepressants, I think I’d already be quite concerned by the article so far. But that is quite a recommendation from the researchers isn’t it? Quite firm advice. The researchers must be certain about the clinical implications of their research.

Apart from of course, they are not, as we’ve already seen from the quote about clinical decisions requiring caution.

Here’s what else they say:

“….the results of the present study as well as the US study present a major dilemma in relation to clinical advice to pregnant women with depression. If antidepressants increase the risk of autism spectrum disorder, it would be reasonable to warn women about this possibility. However, if the association actually reflects the risk of autism spectrum disorder related to the non-genetic effects of severe depression during pregnancy, treatment may reduce the risk. Informed decisions would also need to consider weighing the wider risks of untreated depression with the other adverse outcomes related to antidepressant use. With the current evidence, if the potential risk of autism were a consideration in the decision-making process, it may be reasonable to think about, wherever appropriate, non-drug approaches such as psychological treatments. However, their timely availability to pregnant women will need to be enhanced.”

It’s just not the same as what was written in this magazine is it? I have to wonder how the folk at WDDTY translate “a major dilemma in relation to clinical advice to pregnant women” into what I read as a quite firm statement telling pregnant women suffering from depression to “seek out non drug therapies” I recognise that there is mention of non-drug approaches by the research, but saying “it may be reasonable to think about, wherever appropriate” is very different from saying “should” I really think that once again WDDTY has taken a study and misrepresented it. Either that or the researchers spoke to WDDTY and made additional comments on the research aside from what is published.

Only that is not the case either.

I had email correspondence with Dr Dheeraj Rai, the lead author of the BMJ paper who said,

“It would be unwise to suggest that clinical decisions be based solely on our one study. As we mention in our paper, it is not yet clear whether the associations that were observed between antidepressant use during pregnancy and offspring autism were causal, or related to the risk associated with the underlying depression. Although future research will help answer this question, it is understandable that the possibility of potential harm creates concern. However, decisions regarding treatment require a large number of considerations including type and severity of symptoms, risks to mother and baby, and potential benefits. Doctors or other relevant healthcare practitioners can discuss these with concerned women in relation to their personal circumstances and help them to make informed decisions.”

I know it can’t be easy to simplify such a study into a small accessible, informative snippet, (and I wonder how wise it is to attempt it at all) but I’m just not impressed with the job done here. I hate to think that a pregnant woman struggling to make decisions around antidepressants in pregnancy might read this at take it at face value. And I also hate to think of the Mum who has a child with Autism and took antidepressants during pregnancy, who reads this and ends up feeling to blame.

I also think, that in ignoring the complexities surrounding making decisions around antidepressant use in pregnancy, WDDTY trivialise depression. Their flippant suggestion of seeking out non drug therapies shows no understanding of the condition and the effect it can have on a person. By making such a suggestion, I would argue that WDDTY contribute to the stigma surrounding mental health and potentially their writing could affect more than just the person that chooses to read it. Elsewhere they have done a similar thing with TB patients, ie contribute to stigma, by promoting fear of and discrimination towards people that they would have you believe are suffering from a disease that is incurable (Note: TB is curable).

For responsible advice on anti – depressants and pregnancy read here.

What can be done?

This magazine is damaging. If people trust this magazine with its impressive sounding references without realising the extent to which it misleads, then they will make decisions about health based on wrong information and possibly form attitudes towards patient groups that result in discrimination.

The way they write about cancer and quack cures does nothing but sell false hope. (Read that blog post if you get a chance – it sums up my views on this magazine very well)

Having it available in Smiths and supermarkets with its glossy cover gives it a certain air of respectability it does not deserve. The thought of anyone I care about being seriously ill and picking up this magazine for advice scares me. I wouldn’t want them to use it to educate themselves about depression either, being that it’s something that I personally suffer from.

Myself and many others, would love to raise awareness of the bad reporting in this magazine and get this magazine out of high street stores, and have been making their views known to the relevant companies.

Waitrose have already listened to peoples’ views and have decided to stop stocking it. But the likes of WH Smiths, Tesco, Asda and Sainsbury’s are less responsive. (Sainsbury’s did say they were going to stop selling it, however they appear to have backtracked)

Putting more pressure on these big chains could make a huge difference.

If Tesco and Asda can withdraw their mental health patient costumes because they recognise that selling them reinforces stigma and causes damage to those living with mental illness, then when the damage that this magazine could cause is brought to their attention they ought to act accordingly. If you agree, and fancy letting your views known then here are some email addresses:

[email protected]

[email protected]

Sainsbury’s can be emailed here

[email protected]

The more people who are aware of the misleading information in this magazine the better. So if you agree that this magazine is problematic please spread the word in whatever ways you can. Twitter it(#wddty), Facebook it, blog it, tell your neighbour, if you find a copy speak to the manager of the store or have a word with the pharmacist. Whatever small things you can do. Whatever you think is appropriate.

As always, please let me know if anything is unclear or you feel I have made any mistakes.

See also

Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Autism, Anders Hviid, Dr.Med.Sci., Mads Melbye, M.D., Dr.Med.Sci., and Björn Pasternak, M.D., Ph.D. N Engl J Med 2013; 369:2406-2415:

CONCLUSIONS: We did not detect a significant association between maternal use of SSRIs during pregnancy and autism spectrum disorder in the offspring. On the basis of the upper boundary of the confidence interval, our study could not rule out a relative risk up to 1.61, and therefore the association warrants further study. (Funded by the Danish Health and Medicines Authority.)

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